Periodic Health Examination

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[edit] Periodic Health Examination

Arthur H. Eskew

Even though the concept of prevention is inherent throughout medical care, it has traditionally focused on tertiary prevention in individuals with symptomatic illness. The periodic health examination emphasizes primary and secondary prevention. It involves the performance of tasks that include history and physical examination, laboratory and other tests, and procedures designed to determine an individual's risk for certain preventable conditions and provide guidance to reduce or avoid additional risk or to diagnose those conditions in an early, presymptomatic state in the hope of reducing morbidity and mortality.

The recent compilation of available evidence regarding a broad spectrum of preventive health procedures, largely attributable to the work of the Canadian Task Force on the Periodic Health Examination and the U.S. Preventive Services Task Force (USPSTF), makes it possible for providers and patients to make more informed decisions regarding the risks and benefits of many procedures. Although the benefit of many other commonly recommended screening and preventive procedures remains unproven, the physician has a wealth of expert consensus on which to draw in designing a screening strategy^[1] (Fig. 4-1).

Figure 4-1 Summary of recommendations of the four major studies. *Canadian Task Force recommends that this be done on the basis of clinical judgment. ^†Centers for Disease Control and Prevention recommends that at first visit physician check immunization history for rubella, mumps, poliomyelitis, diphtheria/tetanus toxoids, and pertussis. ^‡If sexually active. A blackened square indicates that a study has considered the maneuver and recommended it. Empty squares indicate that the maneuver was either not considered or considered but not recommended. (From Hayward RA, et al: Ann Intern Med 114:758, 1991.)For legend see opposite page.

This chapter on periodic health examination outlines an approach to evaluating various preventive procedures by discussing barriers and suggesting strategies to ensure that the physician achieves a high rate of compliance with these procedures. Important issues and areas in which physicians can provide support and anticipatory guidance are discussed.

[edit] THE PERIODIC HEALTH EXAMINATION VS. THE ANNUAL PHYSICAL EXAMINATION

The periodic health examination is distinct from the routine or annual physical examination in that it involves the delivery of specific services and procedures based on an individual's age, sex, and estimated risk for disease. It is a process of collecting data, estimating risks and determining specific diseases and conditions for which a patient is at risk, and focusing clinical, cognitive, and diagnostic resources in a fashion that would provide most benefit. It can seldom be accomplished in a single visit or contact with the patient. The concept of an “annual physical” is not obsolete, but rather needs to be modified to incorporate the process and goals of periodic health examination. The history and physical examination provide both the foundation of data on which the preventive care strategy is based and the opportunity to carry out some of that care. When the annual physical reveals an opportunity for intervention, appropriate follow-up visits should be scheduled to emphasize the importance of prevention and reinforce adherence.

Notably, most patient visits are symptom-or disease-related. Therefore any successful preventive health strategy in practice must rely on integrating the periodic health examination into symptom-and disease-related care. This represents a challenge in terms of organizing oneself to carry out the preventive care agenda efficiently.

[edit] PREVENTIVE CARE

Prevention in the primary care setting refers to care that is directed at preserving the health of an individual patient and the community in which the provider practices. The importance and potential effect of preventive care is evident, given the estimate that as much as 50% of the mortality from the 10 leading causes of death in the United States is attributable to potentially modifiable lifestyle factors. The proficient performance of preventive health care requires the physician to possess a firm understanding of clinical epidemiology, the performance characteristics of a broad array of tests and procedures, and clinical decision making. Also necessary is a detailed understanding of an individual's risks, social situation, values, and preferences, as well as knowledge of the incidence and prevalence of conditions and diseases that are important causes of morbidity and mortality in the surrounding community.

[edit] Types of Prevention

Prevention can be divided into several categories. Primary prevention refers to services directed at the prevention of disease before its onset. Examples include immunizations to prevent infectious diseases or counseling to prevent unwanted pregnancy in teenagers. Secondary prevention would involve maneuvers designed to detect diseases at an earlier, presymptomatic stage, so as to decrease morbidity and mortality. The use of mammography to detect early breast cancer before it is palpable or metastasizes is an example. Tertiary prevention is the care directly associated with preventing complications or undue morbidity in persons with established symptomatic chronic disease, for example, using angiotensin-converting enzyme inhibitors to reduce symptoms and prolong survival in chronic congestive heart failure patients. The goal is to provide primary prevention whenever practical or possible, and to fall back on secondary preventive care when it is not. Tertiary prevention is employed when both primary and secondary preventive care for a given condition are either not available, have not been done, or have failed.

[edit] Deciding Which Preventive Services to Provide

In approaching the provision of comprehensive preventive care, the physician is faced with selecting from a large number of screening and early detection strategies and anticipatory interventions for a large number of important conditions and diseases. For those conditions that are potentially amenable to screening, early detection, or anticipatory guidance, the following criteria need to be met:

• The condition should be an important cause of morbidity and mortality in the screened population.
  
• The condition should have a high enough prevalence so as to be suitable for screening. This criterion is important because prevalence will determine the number of false-positives and false-negatives (and hence the positive and negative predictive values) for any given screening test for that procedure. Rare conditions will yield higher false-positive rates on screening tests, regardless of the characteristics of those tests.
  
• An effective screening test or procedure must exist for the condition. This test should be sensitive enough to detect most cases and specific enough to keep the number of individuals misdiagnosed with the condition to a minimum. Ideally, the test should be demonstrated to be effective in controlled clinical trials and in practice situations
  
• The screening test should be low risk and acceptable to individuals undergoing the procedure. The risks attendant to screening can include the direct physical risk of the screening procedure or of subsequent procedures that are performed as a result of a positive screening test (e.g., the risk of bowel perforation with colonoscopy performed to evaluate a positive test for fecal occult blood) or less tangible risks (e.g., the unnecessary anxiety caused if an individual is incorrectly diagnosed with a condition, such as a malignancy). Although usually difficult to quantify, the risk of false reassurance (e.g., a patient ignores symptoms because of a recent negative screening test) also needs to be considered.
  
• There should be a benefit to early intervention for the condition. The most definitive evidence of efficacy for a screening procedure comes from controlled clinical trials demonstrating a reduction in cause-specific mortality resulting from the screening procedure in question. Unfortunately, such evidence exists for few screening tests (e.g., mammography and breast examination for women between the ages of 50 and 74, fecal occult blood testing for individuals past the age of 50). In most instances the physician must rely on indirect evidence, such as case-control or observational studies and expert opinion. Authorities such as the Canadian Task Force on Preventive Services, the USPSTF, and the American College of Physicians have published recommendations and practice guidelines based on rigorous and methodic review of published evidence on a broad variety of screening procedures and preventive services. Other organizations such as the American Cancer Society have relied more heavily on consensus and expert opinion. Such published guidelines form the foundation for the provision of preventive services in general practice. In considering the quality of indirect evidence from observational studies and consensus, the physician must be aware of the common biases in studies involving screening and early detection, such aslead time bias, length time bias, andover-detection bias. Lead time bias refers to the phenomenon by which screening-detected diseases such as cancer will appear to be associated with improved survival in comparison with cases of the same disease that are diagnosed because of clinical symptoms. This is because the disease is detected at an earlier point in its natural history. Actual survival, however, may or may not be affected.Length time bias is introduced because diseases with a longer latency period (and which therefore presumably progress more slowly) are more likely to be detected by screening than diseases with a shorter latency and more rapidly progressive course (and therefore shorter survival).Over-detection bias occurs when screening detects preclinical disease that, if undetected, would not have contributed to the mortality of the affected individuals.
  
• The screening test or procedure should be affordable and/or cost-effective. Such information is rarely availabledirectly but has been estimated for many procedures and has been incorporated into guidelines such as those published by the Canadian Task Force (CTF) and USPSTF.
  

[edit] ELEMENTS OF THE PERIODIC HEALTH EXAMINATION

[edit] Risk Assessment

[edit] Building the Database.

One of the most important aspects of providing effective preventive care during the periodic health examination is a complete and comprehensive clinical database, one used to assess risk of disease and direct anticipatory guidance and screening procedures. Collecting data can be a time-consuming task, part of which the physician may want to delegate to the patient or to office staff through the use of self-completed history forms or questionnaires. They can be completed before the appointment or while the patient is in the waiting room. The form should then be reviewed and clarified with the patient during the examination. The self-completed history form also may alert the physician to a patient's limited English proficiency or illiteracy.

[edit] Medical History.

Perhaps the most central part of any medical database involves the collection of information regarding previous medical diagnoses, their treatment and response to treatment, current and previous medications and allergies, history of immunizations and childhood illnesses, and prior surgical history including response to anesthesia. This is generally accomplished through patient interview, through review of immediately available medical records, and by formally requesting medical records from previous providers or hospitals at which the patient was treated. The information obtained should be recorded on a problem list, which is generally organized into active and inactive problems, and prominently located in the patient's office chart.

[edit] Family History.

A detailed family history is essential for gauging the patient's susceptibility to a variety of important and potentially preventable conditions, and thus determines the primary and secondary preventive efforts (Box 4-1). It may also help the physician to understand the patient's experience and concerns with serious illness in his or her family.

[edit] Social History.

Providing individualized and attentive health care depends on thorough knowledge of the patients and their circumstances. It is also increasingly recognized that there is a correlation between socioeconomic conditions and the risk of cardiovascular disease, cancer, substance abuse, and violence. In addition to occupation, the physician should inquire about education, military service, marital status, relationships, household members, leisure activities, and travel. Any use of alcohol, tobacco, and other psychoactive substances also should be noted.

[edit] Occupational and Environmental History (See Chapter 11.

It has been estimated recently that 390,000 cases of occupation-related illnesses and 100,000 occupational illness–related deaths occur in the United States annually. However, only a small percentage of the illnesses responsible for those deaths are recognized as being related to workplace exposures, since the clinical presentation is rarely diagnostic of occupational disease. Primary care physicians should take an occupational history of each patient as part of a periodic health examination, concentrating on both present and any previous long-term jobs. Efforts should be made to determine the exact nature of the patient's job and to specifically ask about exposure to dust, fumes, solvents or chemicals, noise, vibration, or repetitive motion. The physician should consider the possibility of an occupational cause of illness in patients with dermatologic problems, respiratory illnesses, cardiovascular diseases, emotional disturbances, musculoskeletal pains, malignancies, neurologic problems, hearing losses, traumatic injuries, and certain infectious diseases, such as hepatitis or human immunodeficiency virus (HIV).^[2]

[edit] The Sexual History.

The sexual history of a patient is an essential part of the periodic health examination. A large number of medical, social, and psychiatric conditions can manifest themselves as sexual problems or dysfunction through the life cycle, and yet patients often will not volunteer such information. The physician who cares for adolescents realizes that sexuality is a central focus for them (see Chapter 7 ). The opportunity to offer preventive guidance against sexually transmitted diseases, unwanted pregnancy, and sexual abuse depends on the physician establishing an atmosphere in which sexual problems, concerns, and questions can be openly discussed (see Chapter 56 ). Sexual dysfunction is a problem in the middle aged and elderly, and an often overlooked yet treatable cause of a decreased quality of life.

With the advent of the acquired immunodeficiency syndrome (AIDS) epidemic, as well as high rates of a variety of sexually transmitted infections, it is crucial that the physician ask not only about sexual function but also about sexual orientation and behavior. An effective approach might be to begin a general discussion about high-risk behaviors with a patient and then afford the opportunity for the patient to ask questions. The physician may appropriately choose to collect sensitive information and counsel the patient at follow-up visits rather than at the first encounter, unless a specific complaint dictates otherwise. Although it is common for patients to be reticent regarding their reproductive health concerns, most open up later if the provider establishes that such concerns are welcomed for discussion. See Chapter 34 for more information on effective techniques for taking the sexual history.

[edit] Maintaining and Tracking Data

Many studies have established the utility of using a system of reminders to prompt the physician when certain indicated periodic preventive procedures are due. An example would be a paper spreadsheet in which patient-specific preventive health procedures and proposed frequency are listed in the left-hand margin and dates are listed across the top (Fig. 4-2). As a procedure is performed it is recorded, thus providing a prompt to perform that procedure again after a specified amount of time has elapsed. An effective strategy is to send letters or postcards to patients reminding them that preventive care is due and to call for an appointment. Such applications are perfect for small computers, which can track dates and provide automatic reminders to both patients and physicians. There is some evidence that the use of computerized reminders can enhance performance.^[3] With the increasing practicality and use of electronic patient records in the office setting, it is likely that the automation of these tasks will become standard.

Figure 4-2 Example of a prevention flow sheet. (From Boston Medical Center.)

Regardless of whether a paper or an electronic system is used to keep track of preventive health care, certain characteristics are essential for success. The reminder should be readily available at the time of the patient encounter, and the physician should have the ability to instantaneously update the patient's prevention database. The prevention profile should be customized for each patient, with the physician having the option to suppress reminders when they are no longer warranted. The physician should be able to derive summary statistics so as to gauge overall performance. Peer review mechanisms can be devised within a practice to ensure maximum compliance with previously established guidelines.

Most routine prevention can be organized or carried out by office staff or midlevel practitioners and thus incorporated into waiting time or an exit interview with a nurse. Literature and pamphlets emphasizing the importance of preventive care are often effective in increasing patient awareness and interest and can be prominently displayed in the waiting area and examining rooms.

[edit] Anticipatory Guidance

[edit] Diet and Exercise.

During periodic health examinations, the physician should take the opportunity to provide advice regarding proper nutrition, weight maintenance, and aerobic exercise. Proper diet is being increasingly recognized as central to any preventive strategy. Dietary fat and cholesterol play a major causal role in atherogenesis, and saturated fat intake has been implicated in increasing the risk of colon and breast cancer. Severe obesity (30% above ideal body weight [IBW]) is a risk factor for increased mortality, largely through an increase in cardiovascular and cerebrovascular disease.

The physician should include a baseline dietary assessment in each patient's database. Dietary guidelines appropriate for the general population should be promulgated (e.g., the American Heart Association Step I diet) (see Chapter 71 ). Most patients can be advised to cut down on fatty meats by substituting chicken, fish, and lean meats; to select more fruits and vegetables; and to substitute low or nonfat dairy products for whole fat ones. The maintenance of body weight in the basal state requires approximately 1500 to 1800 calories per day. Patients should reach and maintain their approximate ideal body weight by adjusting intake according to their activity level.

Aerobic exercise is beneficial in reducing cardiovascular risk and helps to reduce stress and promote a sense of well being. In postmenopausal women, weight-bearing aerobic exercise can aid in preventing osteoporosis. Spending as little as 15 minutes a day 3 days a week on modest aerobic exercise such as brisk walking may be beneficial and can be recommended to most patients.

[edit] Alcohol, Tobacco, and Other Substance Use and Abuse.

When one considers the prevalence of alcohol, nicotine, and other chemical dependence, and their propensity to predispose to serious health problems (e.g., trauma, liver disease, cancer, heart disease), it is not so difficult to accept that substance abuse is a major contributor to death and morbidity in the United States.

[edit] Alcohol Use and Abuse.

The primary care physician must be aware of not only the high prevalence of alcohol abuse but also of the highly variable and frequently subtle clinical presentation. Alcohol is toxic to virtually every organ system in the body and can result in a multitude of health effects. The provider should be alert to the potential role of serious alcohol abuse in patients presenting with:

• Excitability or anxiety
  
• Gastrointestinal tract complaints, such as dyspepsia, heartburn, or recurrent diarrhea
  
• Hypertension (especially with poor response to treatment)
  
• Dysrhythmias (especially atrial fibrillation), palpitations, or cardiomyopathy
  
• Depression
  
• Sleep disturbances
  
• Sexual dysfunction
  
• Recurrent major or minor trauma
  
• Multiple somatic complaints
  
• Work absenteeism, interpersonal problems, or marital difficulties
  

Since an individual's alcohol abuse frequently affects the family, the primary care physician may receive the first hints of a problem from the presenting complaints, often subtle, of those nearest the patient.

There are varying definitions of alcohol abuse and dependency. All of them emphasize the consequences of the individual's alcohol intake rather than the frequency or amount of intake and loss of control over drinking despite these adverse consequences. Dependency is distinguished from abuse in that it implies physiologic tolerance and the onset of withdrawal symptoms with abstinence. Harmful drinking is continued heavy consumption of alcohol-containing beverages despite adverse physical or social consequences, but does not necessarily involve physiologic dependence on alcohol. Hazardous drinking is the frequent consumption of 40 to 60 grams of alcohol (about three to four drinks) in men and 28 to 40 grams of alcohol (about two to three drinks) in women. This correlates roughly with drinking to the point of intoxication. Hazardous drinkers are at high risk of progressing to harmful drinking or dependence, and should therefore receive advice to cut down or abstain.

Denial is prevalent, and patients who are harmful drinkers usually will not attribute their problems to a continued use of alcohol, despite overwhelming evidence to the contrary. Adult and adolescent patients should be asked about their use of alcoholic beverages. Those who respond positively should have a more in-depth history taken, one that focuses on the association between alcohol consumption and other events, such as injuries, traffic violations or accidents, arguments, interpersonal conflicts or marital problems, and school or job problems (e.g., absenteeism). In addition, a number of instruments such as the CAGE questionnaire (Box 4-2) or the longer Michigan Alcohol Screening Test (MAST) are available to physicians to screen for dysfunctional alcohol use. The CAGE questionnaire is popular because of its brevity, the ease with which it can be memorized, and the reasonably good sensitivity and specificity when two positive responses are elicited. One positive response also may indicate a significant alcohol abuse problem and is worthy of further investigation. Those patients with a family history of alcoholism, particularly in one or both parents, are at higher risk of becoming alcoholic and should be periodically rescreened ( Chapter 51 ). Physicians should consider advising abstinence in patients with such history

For many patients with problem drinking, there is evidence that office-based intervention by primary care physicians can significantly reduce hazardous and untoward alcohol consumption. A recent randomized controlled study has indicated that a brief intervention on the part of primary care physicians can significantly impact on drinking on the part of nondependent problem drinkers.^[4] Outcomes that are improved include number of drinks per week and frequency of binge drinking, as well as number of days of hospitalization. Long-term improvement and improvement in other alcohol-related outcomes (e.g., injuries and accidents) were not measured, since the follow-up period was relatively brief. Despite the modest effect on frequency and intensity of drinking, routine physician intervention in hazardous and harmful drinkers is supported by the fact that most alcohol-related medical and social problems occur in nondependent problem drinkers, as well as by the low risk posed by advice-giving and counseling.

Useful office-based interventions characteristically involve advising abstinence, or in instances where patients do not have abstinence as a goal, advice on limiting consumption to amounts not generally considered harmful (one to two drinks per day in men and zero to one drink per day in women). Possible untoward effects and contributions of

alcohol on current health problems or symptoms should be emphasized.

[edit] Tobacco (Nicotine) Dependency.

Despite increasing public knowledge about the adverse consequences of tobacco use, smoking continues to contribute to an enormous burden of suffering in the United States (see Chapter 57 ). It is important that the primary care physician ask all patients regularly about tobacco use. Those who do smoke should be educated about both its adverse effects and the health and economic benefits of quitting (e.g., a one-pack-per-day smoker now spends about $1000 a year on cigarettes), and should be advised to quit. A small but significant number of patients quit simply because their physician advised them to do so. See Chapter 57 for smoking cessation techniques.

[edit] Other Substances.

The clinical presentation of the abuse of substances other than alcohol varies with the chemical in question, but abuse syndromes share a common ground of social and relationship dysfunction, financial problems, and trauma (see Chapter 52 ). Cocaine use can cause catastrophic cardiovascular and neurologic events, as well as depression and panic disorder. Marijuana smoking can lead to chronic lung disease. Injection drug use is a leading cause of HIV infection, hepatitis, endocarditis, and local infectious complications.

As with alcohol, the primary care physician should ask about other substance use and take a more in-depth history of those patients responding affirmatively. Treatment referral should be offered to patients who continue their abuse. Patients who use a substance despite evidence of significant medical or social consequences or whose history suggests a loss of control over the substance should be strongly urged to seek treatment.

[edit] Domestic Violence.

Domestic violence traditionally has been an underreported and underrecognized problem in primary care populations. Although as many as 2 to 4 million women are battered by their husbands or significant others, only about one in 20 is diagnosed with the battering syndrome by a physician, since few women disclose abuse, despite the fact that many consider their physician as a source of help. Homes in which domestic violence is perpetrated by men against women (the vast majority of domestic violence) are far more likely to include abused and neglected children, and those children are apt to grow up to abuse their spouses and children. Domestic violence is a major cause of suicide among women and homicide committed by women against their husbands or significant others. There is a strong association between domestic violence and alcohol and substance abuse, both on the part of the perpetrator and the victim (see Chapter 59 ).

Victims of battering occasionally present with recurring physical evidence of trauma but more commonly present with nonspecific constellations of symptoms, such as depression, fatigue, unexplained abdominal or pelvic pain, or multiple somatic complaints that are frequently atypical. The prevalence of physical, emotional, or sexual abuse in these patients may be as high as 45%.

The most effective strategy for detecting domestic violence is to ask, since patients rarely volunteer the information. Statements such as “Marriages (or relationships) are frequently very difficult” and “Does your husband (or partner) ever strike you or make you feel bad about yourself?” convey a message of concern, letting the patient know that the physician is willing to discuss such subjects. Surveys on the issue indicate that most patients not only do not mind being asked, but actually expect the inquiry. It is important to assure patients about the confidentiality of the conversation, since they may fear reprisal. Younger women who are beginning the coupling process should be asked in a neutral fashion if they have been coerced into performing sexual acts through intimidation or physical violence. Children and adolescents should be asked about arguments at home and their consequences, as well as about their parents' usual methods of punishment.^[5]

Although it is tempting to do so, the primary care physician should avoid the urge to rescue the victim. The provider's main role is that of counselor and supporter. The victim should receive the message that violence is wrong and illegal and that there are laws offering protection. Careful documentation of the history and physical findings (including photographs, if possible), as well as x-rays done to evaluate injuries, may assist the patient in pursuing legal protection later. The physician should at least provide the telephone number of a local violence hotline or battered person's shelter. If the situation is more urgent, the patient should be encouraged to notify the local authorities. In some instances the actions taken by the physician are governed by local mandated reporting laws, such as in cases of suspected abuse of a minor or an older adult. The treatment of victims with severe physical and psychologic sequelae should be referred to providers experienced in the management of domestic violence. See Chapter 59 for further discussion.

[edit] Adolescent Health Issues.

Adolescence is a time of rapid emotional and physical change, when many lifestyle factors that are likely to influence long-term health are established. Health issues of particular salience to adolescents include teenage pregnancy; sexually transmitted diseases (STDs); violence and injuries; substance abuse, including alcohol and tobacco; physical and sexual abuse; depression and suicide; eating disorders and proper nutrition; and exercise. Despite the apparent opportunity for meaningful primary prevention, adolescents remain medically underserved. Young men, in particular, are unlikely to see physicians except for sporadic, symptom-related care, while young women may be seen more frequently for routine gynecologic and family planning visits. These occasions should be viewed as an opportunity to ask about concerns, to screen for possible problems, and to provide appropriate anticipatory guidance and referral as necessary. The primary care physician should be familiar with and comfortable asking about these issues. Participation in school-based programs and clinics such as those providing presports participation physicals may afford the opportunity to intervene with a broader sample of the adolescent population in a community.

[edit] Teenage Pregnancy and Sexually Transmitted Disease (STD) Prevention.

Unwanted teenage pregnancy is occurring in epidemic proportions. Forty percent of young women in the United States become pregnant by the time they are 19 years old, 20% become mothers, and 15% have therapeutic abortions. The teenage abortion rate in the United States exceeds the teenage pregnancy rate in other Western countries (e.g., in Sweden, a young woman is half as likely to become pregnant despite a sexual activity rate 50% higher than that of adolescent women in the United States). This statistic has been attributed to the greater availability and acceptance of contraceptives in the European teenage population. The potential for increasing contraceptive use is apparent when one considers that 51% of American teenagers do not use contraception on first intercourse, and 20% of the young women who become pregnant do so within 1 month of first intercourse.

The primary care physician may wish to become active on a communitywide basis by advocating school-based educational programs and by breaking down barriers that inhibit the availability of contraceptives for teens. In the absence of such programs, the physicians themselves are the major source of contraceptive information for teens. Unfortunately teens are unlikely to initiate a discussion about sexual concerns, leaving it to the physician to inquire in a neutral, nonthreatening fashion at unrelated visits (e.g., a routine gynecologic appointment). Phrasing questions such as “Many women (or men) your age have questions about sex and avoiding pregnancy. I would be happy to answer any questions you have today or in the future if you would like” creates an atmosphere in which teenagers can feel that the subject of sexuality is fair territory for discussion and that their provider is an ally. Toward this end, the physician should stress the confidentiality of the discussion and avoid adopting a judgmental or moralizing attitude. Physicians should familiarize themselves with state laws regarding the treatment of minors, but in general it is unlikely that a physician will be subject to legal recourse for prescribing birth control to a teen who requests it. Federally funded facilities are required to provide birth control to a minor who requests it, and although individual physicians have the right to refuse, they are required to provide referral to a facility or physician who will.^[6]

Primary and secondary prevention of both teenage pregnancy and STDs should include a discussion about the physiology of reproduction and about transmission of STDs, and information about behaviors and contraceptives. Oral contraceptives (OCPs), although effective at preventing conception, may not be an ideal method for teens, in that they require advanced planning and strict compliance, and provide no protection against STDs. Barrier methods, particularly condoms, are better in the latter regard, but less effective in the former. Therefore condoms plus another method, such as OCPs, should be recommended for adolescents who choose to remain sexually active. The physician should stress that no contraceptive method other than abstinence is 100% effective in preventing HIV transmission. It is important to discuss the intense social, emotional, and physical impact of becoming sexually aware and to educate teens on the potential advantage of postponing sexual intimacy until later in adulthood.

[edit] Violence, Risk-Taking Behavior, and Injury Prevention.

Homicide is the third leading cause of death among 15-to 24-year-old men in the United States and is now recognized as a major health problem. Physicians should routinely ask about fighting and injuries, and the circumstances under which they occur. The possibility of substance abuse and its relationship to fighting or injuries should be explored, and the connection emphasized to the patient. The association of substance abuse with domestic violence must be kept in mind, and patients should be routinely questioned regarding their homelife and their parents' attitudes toward punishment. The teen with a history of violence should be warned about the risk of death and/or serious injury, and given general advice regarding nonviolent techniques for resolving conflicts. Those with a history of alcohol or drug use should be offered referral for treatment.^[7]

Injuries are the leading cause of death in persons 1 to 44 years old, and automobile-related accidents are the most important source of injury.^[8] Physicians should routinely point out the effectiveness of seatbelts, especially those with shoulder restraints, and encourage their use even for brief trips. The use of child restraint seats should be encouraged, since an unrestrained child is 11 times more likely to die in an accident than a restrained one. Fortunately, the physician is assisted in these endeavors as more and more states invoke mandatory seatbelt and child restraint laws. Alcohol use is at the root of approximately 50% of all traffic fatalities, and adolescents should be advised against drinking and driving.

Physicians also should promote the use of other appropriate protective equipment (e.g., head, wrist, elbow, and knee protection during in-line skating, and bicycle and motorcycle helmets).^[9]

[edit] Depression and Suicide.

Suicide is the second leading cause of death among persons 15 to 24 years old. Young women attempt suicide more frequently than young men; however, men are more likely to succeed, and therefore account for the vast majority of suicide-related deaths in this group. Physicians should be aware of the association between an adolescent's suicidal behavior and major life stressors, such as school difficulties, domestic discord and abuse, parental divorce, and relationship problems. Additional factors include substance abuse, antisocial behavior, homosexuality, and major depression. The history of prior suicide attempts is the strongest risk factor. None of the other factors alone or in combination have been found to have value in defining a high-risk individual. The periodic health examination of the adolescent should include routine questioning about social functioning, home life, and mood, as well as screening questions for the vegetative signs of depression. Those who report serious suicidal ideation should be further assessed for the “lethality” of their plan (e.g., having a specific method in mind, having already obtained the planned means). Those who are determined to act must be hospitalized; those less intent can be managed as outpatients. The complexity of the average teenager's social and maturational hurdles, as well as the frequent need to include parents and other family members in the treatment plan, makes referral to a provider skilled in this area almost always a necessity.

[edit] Eating Disorders.

As a result of definitional and reporting problems, the exact incidence of eating disorders is unknown; however, it is believed to have increased dramatically in the past 2 decades. The reasons for this are unclear but are believed to be associated with the current trend equating thinness with beauty. Women outnumber men with these disorders by as much as 25 to 1. Anorexia nervosa and bulimia nervosa may present quite overtly in their severe forms or subtly with minor degrees of severity. The routine care of the adolescent should include a dietary history, not only to provide anticipatory guidance regarding nutritional habits, but also to screen for unusual attitudes and obsessions about food, eating, distorted body image, or inappropriate self-perception that the adolescent is overweight. Adolescents with eating disorders frequently present with depressed mood and/or anxiety and hyperactivity. They often experience problems at home, in school, and at work, and may be socially isolated. Any of these signs should raise suspicion. Additionally, the physician should be aware of the possibility of an eating disorder in an adolescent who presents with unexplained electrolyte abnormalities, especially hypokalemia, who is remarkably underweight (more than 15% below IBW); shows a delay or plateau in the development of secondary sex characteristics; has primary or secondary amenorrhea; displays severe periodontal disease (a result of habitual purging of stomach contents); or has difficulty adjusting socially. Patients with bulimia nervosa may show wide swings in body weight over months or years, but most often present at or near their IBW. Bulimics suffer the most severe metabolic derangements, which may be life-threatening. Hospitalization for fluid and electrolyte replacement is indicated in extreme cases, even without the patient's consent if his or her refusal constitutes an immediate threat to survival. Management of less severe cases can be done on an outpatient basis, although referral to a clinician experienced in these disorders (usually a psychiatrist, psychiatric nurse, or psychologist) is wise. See Chapter 55 for more information on the diagnosis and treatment of eating disorders.

[edit] Office-Based Screening

A comprehensive discussion of all screening procedures that the primary care physician may wish to consider is beyond the scope of this chapter; however, several of the major targets of screening in primary care practice are discussed here.

[edit] Colorectal Cancer Screening.

Colon cancer is the second most common lethal cancer in the United States, affecting both men and women equally. Lifetime incidence for persons of average risk is approximately 6%, but is two to three times higher for persons with an affected first-degree relative. Patients with a familial polyposis syndrome have a risk 20 to 30 times higher, virtually a 100% lifetime risk. Persons with ulcerative or Crohn's colitis also have a greatly increased risk, as much as fivefold to sixfold lifetime risk.

There is mounting evidence that colorectal cancer may be linked to certain dietary factors and therefore may be somewhat preventable. Treatment of advanced disease remains unsatisfactory, placing an emphasis on screening to detect early, potentially curable disease.

The physician has a relatively wide array of useful screening procedures that vary dramatically in terms of availability, acceptability, efficacy, and cost. For most of these procedures, controlled, prospective data demonstrating a reduction in mortality from colorectal cancer are lacking. Therefore a screening strategy must be chosen based on a patient's estimated risk and preferences.^[10]

[edit] Digital Rectal Examination.

The digital rectal examination (DRE), in which the examiner inserts a gloved finger into the rectum to detect palpable neoplasia, is probably of minimal efficacy, since only about 10% of lesions arise within 7 cm of the anal verge. The main utilities are that the DRE allows direct palpation of the prostate gland in men and can be combined with office stool guaiac testing (although some recommend against office-based screening because of the potential of inducing bleeding by insertion of the examiner's finger). There is no convincing evidence either for or against the routine performance of DRE.^[11]

[edit] Stool Guaiac Testing (Fecal Occult Blood Testing [FOBT]).

Stool guaiac testing is based on the detection of peroxidase-like activity in the stool, a result of the presence of occult blood. Procedurally, the patient is instructed to test three consecutive stools by sampling two different areas of each stool using a wooden spatula or similar implement and applying it to the two slide windows of a guaiac testing card. One card is needed for each of the three bowel movements. The cards are subsequently developed by placing a few drops of a hydrogen peroxide solution onto them. A test is positive when any of the six slide windows turn blue, denoting the presence of heme. One week before testing it is recommended that the patient be placed on a meat-free diet that also omits foods high in peroxidase (e.g., horseradish, melons, and cauliflower). To minimize the false-negative rate, the cards should be developed within 1 week of sampling. Controversy has surrounded rehydrating the slides by placing a drop of deionized water on the slide before adding the developer solution. This increases the sensitivity of the test but also raises the false-positive rate and lowers the positive predictive value. Stool guaiac testing has an approximate sensitivity of 50% to 60% for malignancy (lower for polyps), and a positive test has a 5% to 10% positive predictive value for malignancy and 15% to 45% for polyps. Any patient with a positive result should be further investigated with colonoscopy or air contrast barium enema with a flexible sigmoidoscopy (see Chapter 105 ).

There is evidence from a randomized controlled study by Mandel and colleagues (the Minnesota Study) showing a 33% reduction in cause-specific mortality through annual stool guaiac testing with rehydration before developing the cards.^[12] Two more recent European studies of biennial screening without rehydration have shown a smaller treatment effect of 16% and 18% reduction respectively in cause-specific mortality.^[13][14] Similarly a recent meta-analysis of screening trials found a 16% reduction.^[15]

[edit] Sigmoidoscopy.

The use of sigmoidoscopy to screen for colorectal cancer is being reevaluated. The American Cancer Society recommends flexible sigmoidoscopy every 3 to 5 years following two negative examinations 1 year apart for persons of usual risk over the age of 50, based on data from uncontrolled, observational studies. The USPSTF and National Cancer Institute have not recommended routine sigmoidoscopy, citing a lack of evidence of efficacy. The theoretic advantage and intuitive appeal of sigmoidoscopy stem from the well-accepted natural history of colorectal cancer, in which most invasive cancers arise from premalignant, adenomatous polyps, a process that is believed to take an average of 7 to 10 years. Using a sigmoidoscope, the examiner can identify, biopsy, and/or remove suspicious lesions within reach of the instrument. Sigmoidoscopy can be considered therefore to be virtually 100% sensitive and specific within its reach, and 60% of all potential cancers arise within reach of a 65-cm flexible sigmoidoscope. Although there are no prospective controlled studies demonstrating that screening with sigmoidoscopy reduces mortality from colorectal cancer, studies do demonstrate that malignant lesions discovered during sigmoidoscopic screening are less advanced (Duke's stages A and B) than lesions that present with symptoms, a trend also demonstrated with stool guaiac screening. If one accepts this shift toward less advanced lesions as a surrogate end point, then the evidence strongly supports the use of sigmoidoscopy for screening.

Weighed against the use of sigmoidoscopy are its relatively low availability (although this procedure is well within the purview of the generalist), its significant cost, greater discomfort, and the risk of bleeding or perforation from the procedure. If performed, the sigmoidoscopy should be combined with annual stool guaiac testing.

[edit] Colonoscopy.

The use of colonoscopy to screen for colorectal cancer offers the advantage of direct visualization of the entire colon from rectum to cecum, with the removal or biopsy of all suspicious lesions. This is achieved through greater discomfort, a more difficult bowel preparation, much greater cost, and higher risk of perforation. Furthermore, it is estimated that the increase in efficacy over a program of stool guaiacs, DRE, and sigmoidoscopy is marginal. For all of these reasons colonoscopy is rarely used purely for screening in persons of usual risk, but is quite reasonable and frequently recommended for persons at much greater risk (e.g., first-degree relative with colon cancer, familial polyposis syndromes, or inflammatory bowel disease [IBD]).

In summary, primary care physicians should place emphasis on colorectal screening as an important avenue to reduced morbidity and mortality in their practice population. Many organizations recommend that annual FOBT and flexible sigmoidoscopy every 3 to 5 years should be offered to persons of usual risk beginning at age 50. The USPSTF concludes that there is strong evidence in favor of screening, but it is unclear if the optimal strategy is FOBT or sigmoidoscopy or both. Colonoscopy every 10 years may be a reasonable alternative, but the lack of trial data, increased risk, and cost need to be considered. Persons with a family history of colon cancer, particularly in first-degree relatives with onset before age 60, should begin screening at age 40 with either FOBT annually and sigmoidoscopy every 3 to 5 years or colonoscopy every 10 years. If there is suspicion or history of familial polyposis or hereditary nonpolyposis colorectal cancer, referral should be made for surveillance colonoscopy as well as genetic counseling and testing.

[edit] Cervical Cancer Screening.

A woman of average risk in the United States has an approximately 0.7% cumulative lifetime risk of developing invasive carcinoma of the uterine cervix, and a 2% lifetime risk of carcinoma in situ. Although these risks are relatively low in comparison with other important malignancies, they are heavily affected by screening, and, according to estimates, would be two to three times higher in an unscreened population. The risk is increased in African-Americans and Latinas, as well as with early age of first intercourse, multiple sexual partners, cigarette smoking, and oral contraceptive use.

Based on a wealth of empiric evidence, the efficacy of cervical cancer screening using the Pap smear is widely accepted. Numerous population-based reports looking at the effects of widespread screening studies have demonstrated a dramatic impact on the incidence of invasive cervical carcinoma and carcinoma in situ.^[16]

Some controversy remains regarding the age to begin screening, the age to end screening, and the optimal frequency at which to screen. It appears that to maintain most of its efficacy, screening should begin in a patient's early 20s at the latest and continue until the age of 65. Beginning at age 17 or continuing until age 75 results in only marginal gains at a substantial cost, if considered on a population-wide basis. Notably, the efficacy of screening from age 65 to 75 or later is much higher if the woman has not had a prior Pap smear. Likewise, screening annually rather than every 3 years results in marginal benefit. At intervals greater than every 3 years the benefit falls off significantly, but screening still retains approximately 65% efficacy at an interval of every 10 years. Ultimately, decisions regarding the age to begin screening and the interval at which to screen should be based on the patient's preferences, as well as on an assessment of her baseline risk. Current recommendations are for screenings to begin at age 18 or at the beginning of sexual activity, with annual examinations through the age of 65. This protocol is estimated to reduce invasive cervical cancer by more than 90%.

[edit] Breast Cancer Screening.

Breast cancer is currently the second most common cause of cancer death among women. At present, a woman of average risk has a one in nine cumulative lifetime risk of developing breast cancer, with the risk increasing two to three times in those who have a first-degree relative afflicted. Of those who develop breast cancer, approximately one half will die from the disease. In the absence of knowledge regarding effective primary prevention, the primary care physician must emphasize early detection and cure. Fortunately, effective screening strategies exist that utilize one-and two-view mammography, singularly and in combination with physician-performed breast examination. However, many unanswered questions and controversies remain.^[17]

The evidence for the efficacy of mammography with and without physician-performed breast palpation in lowering breast cancer–related mortality for women between the ages of 50 and 74 has been demonstrated by a number of large randomized trials and is accepted by most authorities. The magnitude of this reduction ranges from approximately 15% to 30% and may be higher for women in the 50-to 60-year-old age group.^[18] Standard recommendations for women of average risk include annual two-view mammography in combination with at least annual physician-performed breast palpation beginning at age 50.

[edit] Controversies in Breast Cancer Screening

[edit] Screening in younger women.

No study has definitively demonstrated a benefit of mammography with or without breast palpation in the 40- to 49-year-old age bracket, although several studies have strongly suggested an emerging trend. A recent meta-analysis of the available randomized controlled trials also found no evidence of a benefit in women between 40 and 49 in terms of cause-specific mortality.^[19] Factors contributing to a lesser efficacy of screening in this cohort include a lower incidence of breast cancer in younger women, radiographically denser breasts that may conceal important mammographic abnormalities, and the detection of tumors that may be less amenable to therapy. Factors that further weigh against mammographic screening in this age group include potentially higher risk of radiation-induced breast cancer, both through higher sensitivity of the breast tissue and through a longer period of time over which a woman will be exposed.

The USPSTF currently finds that there is insufficient evidence to recommend for or against mammographic screening of women of usual risk in this age group.^[20] The American Cancer Society, American College of Obstetrics and Gynecology, National Cancer Institute, and American Medical Association are in favor of screening. The American College of Physicians and the Canadian Task Force on the Periodic Health Examination recommend against screening in women less than 50 years old.^[21]

[edit] Screening in older women.

Most available studies address the use of breast palpation and mammography in women 40 to 75 years old. Evidence suggests that women between the ages of 50 and 69 derive the majority of mammography's benefit. A possible reason for a lack of efficacy for mammography in older women is the tendency for postmenopausal breast cancer to behave in a less aggressive manner and to respond readily to hormonal therapy. The use of mammography in women over the age of 75 should therefore be individualized. Most authorities recommend the continued use of physician-performed breast palpation with or without breast self-examination in women older than 75, while recommendations regarding mammography vary.^[21]

[edit] Breast self-examination.

Although widely recommended and taught, breast self-examination (BSE) has not been subjected to enough scientific study to allow specific recommendations regarding its use. It is likely that efficacy is linked to technique, method of instruction, and reinforcement. The most favorable estimates place sensitivity at approximately 25%. Since the false-positive rate, and hence specificity, is unknown, its value as a screening procedure, either alone or in combination with other modalities, cannot be determined. However, BSE may have higher sensitivity in younger women for whom mammography may be less desirable. If employed, it is best used either as a sole screening strategy when other modalities are unavailable or impractical or in combination with mammography and physician-performed breast examination, where it has the potential to detect interval tumors (cancers that become manifest between screening visits).^[22]

[edit] Frequency of screening.

The optimal frequency of screening is unknown, but data from several studies suggest that the mortality reduction increases as the interval between screenings decreases. Annual mammography is most widely recommended, BSE is generally recommended at monthly intervals, and a physician-performed breast palpation should be done at least annually.

[edit] Prostate Cancer.

Prostate cancer is currently the most common malignancy, and the second most common cause of cancer-related death, in men in the United States (see Chapter 152 ). The incidence of prostate cancer increases steadily with advancing age, and may approach 100% in men past 90, if one includes small microscopic foci of disease. Since effective primary prevention is unclear, early diagnosis in the hopes of curative therapy has been emphasized as an effective strategy to combat this disease, which accounts for more than 35,000 deaths in the United States annually. The lifetime cumulative risk of developing prostate cancer is approximately 10% in men of average risk. Risk doubles for men who have a first-degree relative affected by prostate cancer, and the risk redoubles for each additional first-degree relative affected. For reasons that are not understood, African-Americans have a 50% increased risk of developing prostate cancer.

Despite the significant burden of disease from prostate cancer, poor knowledge regarding natural history and prognostic factors, as well as a lack of prospectively determined proof of the efficacy of screening in terms of disease-specific mortality reduction, poses significant decision-making difficulties for the physician regarding the potential benefit of screening.^[23] Therefore the standard screening modalities are discussed in terms of their characteristics and potential efficacy in detecting disease, and remaining controversies and limitations are emphasized.

[edit] Digital Rectal Examination.

An annual DRE is recommended for men over the age of 40 by the American Cancer Society, both to detect prostate cancer and to act as part of a screening strategy for colorectal cancer. Early studies suggested benefit for populations screened for prostate cancer by this method based on survival comparisons with historic controls. Furthermore, there seems to be a shift toward the detection of disease confined to the gland in serially screened patients. Although the sensitivity, specificity, and positive predictive values of DRE have been estimated, they are likely to be overestimates. Tumors arising in the medial lobe and transitional zones (approximately 30% of significant tumors) are not readily detectable. The DRE's ability to detect disease confined to the gland is apparently limited, since approximately 50% of tumors detected by DRE that have clinically limited-stage disease (stages A and B) are found to have more advanced disease after surgical staging. In addition, there is large interobserver variability. Despite this, 30% of significant prostate cancers are potentially detectable at a curable stage by DRE.

[edit] Prostate-Specific Antigen.

The prostate-specific antigen (PSA) is a serine protease produced only in the prostate gland and detectable in the serum. Because both normal and malignant prostatic cells produce PSA, it can be elevated in a variety of prostate disorders, most commonly benign prostatic hyperplasia (BPH). Although the degree of elevation is generally higher with prostate cancer, there is enough overlap between benign and malignant disease, particularly early malignant disease, to necessitate further investigation. Values between 0 and 4 ng/ml are considered normal, although they are not inconsistent with early cancer. Values greater than 10 are highly specific for prostate cancer, although many patients with values in this range already have incurable disease. In the range from 4 to 10 ng/ml, the PSA levels generated by most curable prostate cancers, there is maximal overlap between benign and malignant disease, making interpretation difficult. Thus PSA has neither a sufficient sensitivity nor specificity to be useful as a sole screening method, and its routine use remains controversial for men of usual risk. If used, it should be combined with the DRE, since the combination of tests has improved sensitivity over either test alone.

[edit] Percent Free PSA.

Percent free PSA compares the amount of free PSA to bound (complexed with protease inhibitors) in the serum. Free PSA is expressed as a percentage of total serum PSA. For those men whose PSA is between 4 and 10 ng/ml, and whose DRE is not suspicious for malignancy, measuring the percent free PSA can improve specificity to the point where approximately 20% of unnecessary biopsies can be avoided.^[24]

[edit] Transrectal Ultrasound.

Like DRE and PSA, transrectal ultrasound (TRUS) lacks the adequate sensitivity and specificity to be used as a sole screening method, especially considering its cost and lesser acceptability. Although it has the ability to detect many tumors missed by DRE, TRUS adds little when both the DRE and PSA are normal. At present, the main role of TRUS is in guiding biopsies.

[edit] Current Recommendations.

The USPSTF and Canadian Task Force do not recommend screening for prostate cancer. The American Cancer Society and American Urological Association are in favor of screening men between the ages of 50 and 60. Most other authorities recommend counseling on risks and unknown benefits of screening prior to proceeding.^[25]

[edit] Screening for Coronary Heart Disease Risk with Serum Cholesterol.

Coronary heart disease (CHD) is the most common cause of death in the United States and in many Western countries and causes a large amount of morbidity. The established risk factors for CHD include male sex, family history of premature CHD, hypertension, cigarette smoking, sedentary lifestyle, obesity, diabetes, and elevated serum cholesterol. There is accumulating evidence elevated homocysteine levels are another important risk factor, which may be modifiable through vitamin supplementation, especially folate, pyridoxine, and vitamin B₁₂. Screening for elevated serum cholesterol has become a central focus of the periodic health examination. This is a result of the importance of CHD in the population; the establishment of a causal link between elevated serum cholesterol (specifically the low-density lipoprotein [LDL] fraction) and CHD; the synergy with and interplay between elevated serum cholesterol and other modifiable cardiovascular risk factors; the availability of management strategies that can significantly lower total and LDL cholesterol; and the growing amount of experimental evidence that interventions lowering serum total and LDL cholesterol result in a reduced risk of CHD and CHD-related mortality, and even overall mortality.

The National Cholesterol Education Program of the National Heart, Blood, and Lung Institute has issued guidelines for routine screening, detection, and follow-up and treatment of persons with elevated serum (LDL) cholesterol.^[26] Although the optimal interval is not firmly established, screenings are recommended at least every 5 years for all adults over the age of 20, regardless of other cardiovascular risk factors. Screening is accomplished through the measurement of a random total serum cholesterol and a random high-density lipoprotein (HDL) cholesterol. Individuals with a total serum cholesterol under 200 mg/dl are considered to have a desirable cholesterol. Total serum cholesterols between 200 and 239 mg/dl are considered borderline, and a total serum cholesterol of 240 mg/dl or more is considered to be elevated. An HDL less than 35 mg/dl adds an additional risk factor to be used in following the guideline, while an HDL greater than 60 mg/dl subtracts a risk factor. A reanalysis of the subjects in the placebo arms of the Lipid Research Clinics Coronary Primary Prevention Trial^[27] and participants in the Framingham study found that using the total cholesterol to HDL cholesterol ratio was superior to the LDL level in predicting risk of CHD events. A cutoff of 5.6 for women and 6.4 for men was suggested as identifying individuals at increased risk (roughly the 90th percentile).^[28] Individuals with a ratio less than 4 are at lower than average risk, and this may be an appropriate time for primary prevention.

For individuals with either borderline or elevated total serum cholesterol, further investigation with a fasting lipoprotein electrophoresis and triglyceride is recommended in order to determine the LDL cholesterol and HDL cholesterol. LDL values less than 130 are desirable and do not warrant further specific intervention. Individuals with either borderline (130 to 159 mg%) or elevated (greater than 160 mg%) are candidates for varying degrees of dietary intervention and possibly drug therapy, depending on response to diet and the presence or absence of established atherosclerosis or other cardiovascular risk factors. The reader is referred to Chapter 71 for more information on the detection and management of lipid disorders.

[edit] Laboratory Testing.

There is no evidence to support widespread screening with blood work or urinalysis in adults without specific clinical conditions or risk factors (except serum cholesterol, above). Many physicians, for example, believe that obtaining routine complete blood counts (CBCs) is indicated in premenopausal women, since as many as 30% may be iron deficient. Similarly, although the prevalence of both subclinical and overt hypothyroidism varies markedly among studies, up to 10% of women greater than 40 years old may be subclinically hypothyroid and 1% to 2% may be overtly hypothyroid. Some physicians therefore routinely assess thyroid-stimulating hormone (TSH) levels on women over 40 years of age. Although there is no experimental evidence of efficacy, this procedure may be cost-effective for older women.^[29] Routine urinalysis, although not rigorously evaluated and not recommended by the USPSTF, is performed by some physicians in hopes of detecting early renal and bladder malignancies. Most physicians obtain a rapid plasma reagin test (RPR) or venereal disease research laboratories test (VDRL) at least once on adults, and periodically if the patients engage in high-risk sexual practices, have a history of STD, or reside in urban areas.

[edit] Immunizations and Chemoprophylaxis

Providing immunizations is one of the most important functions of the primary care physician. This important topic is addressed fully in Chapter 5 (Immunization), as are travel-related immunization procedures and chemoprophylaxis.

In light of the recent increase in incidence of tuberculosis, purified protein derivative (PPD) testing is an important preventive procedure both for certain individuals and for the community at large. Persons with known exposures, who are employed in health care–related fields or who have immigrated from endemic areas, should be screened and considered for appropriate chemoprophylaxis if positive. Nursing home residents should be screened with a two-step procedure on admission and annually. For a full discussion see Chapter 74 .

[edit] SPECIAL ISSUES IN THE ELDERLY

[edit] Prevention

Prevention in the elderly should generally be focused on attempts to deter frailty and functional decline. The causal factors behind loss of vitality in the elderly include the realms of lifestyle, social factors, and the accumulation of chronic illness, in addition to the loss of physiologic reserve that is part of normative aging. Early research suggests that attention to modifiable factors such as proper diet, exercise, and avoidance of tobacco and alcohol, as well as attention to such common geriatric problems as sensory loss, social isolation, and depression, may go far in improving the aging process. Many of the topics touched on in this chapter are discussed more fully in the section on geriatric medicine in Chapter 8 .

Whether or not an “elderly” person should be subjected to routine preventive services recommended for all adults deserves special consideration. There is a paucity of evidence regarding the risks and benefits of common preventive services in the elderly (here defined as individuals over the age of 75). The decisions should probably not be made based on some arbitrary age cutoff, but rather based on the patients' functional status and general health, some consideration of actuarial survival, the natural history and epidemiology of the target disorder, and the known magnitude of the potential benefits and risks in patients in whom the intervention has been studied.

[edit] Hearing Impairment

More than one third of all individuals over the age of 65 have audiometrically detectable hearing loss, and a substantial proportion report a significant decrease in the quality of their lives as a result. There is evidence linking hearing loss to social isolation, and possibly to depression and cognitive decline.

Given this significant burden of suffering, efforts at screening and detection seem advisable. However, such common bedside examination techniques as the whisper test, the finger rub test, and the tuning fork test are unlikely to be either sensitive or specific enough to serve as reliable screening tests. There is good evidence that a handheld audioscope performs very well in this regard, provided it is combined with visual inspection of the auditory canals and removal of any obstructing earwax. In addition, standardized questionnaires have been developed that focus on social or communication impairment as a result of hearing loss.

Once a potential hearing problem is uncovered through the use of a screening tool, formal audiologic evaluation should be arranged. Despite the real concerns about hearing aid compliance and the cost of these devices in the absence of Medicare reimbursement, many patients benefit greatly.

[edit] Visual Impairment

The suffering from visual impairment in older individuals is probably similar to that from hearing impairment. However, because glasses are less socially stigmatizing than hearing aids, and decreasing visual acuity interferes more with important activities like reading and driving, many persons seek eye examinations and corrective prescriptions from ophthalmologists and optometrists directly.

The major causes of visual decline in the elderly, other than refractive error, include glaucoma, senile macular degeneration, cataracts, and diabetic retinopathy. There is probably benefit to early detection of glaucoma, although the primary care physician is relatively limited in screening options. Schiøtz's tonometry is not widely recommended for screening, a result of its relative difficulty, operator dependency, and questionable reliability. Thus screening still lies in the hands of the specialist. As there is no effective treatment for senile macular degeneration, screening for this disease is probably unwarranted. Laser therapy for early proliferative diabetic retinopathy is effective in reducing the incidence of severe visual loss by as much as 50%; however, routine funduscopic examination is not sensitive enough to detect most instances of this disease in its early stages, before visual acuity is lost. Cataracts are readily detectable on routine ophthalmoscopic examination, but determining the amount of visual impairment attributable to them requires sophisticated methods, and there is probably no benefit to early treatment.

This is not to imply that primary care physicians should not routinely ask about or examine their elderly patients' vision. Visual loss that has developed gradually may go unnoticed or unreported, or the patient may accept it as part of being old. Visual loss may be an important, yet reversible factor in patients presenting with depression, cognitive decline, falls and injuries, or other functional decline. Visual acuity is readily testable using a Snellen's wall chart or pocket visual screener. Patients with best corrected vision less than 20/40 or with decline since their last examination should be referred for further evaluation.

All patients older than 40 should probably have a routine eye examination by an ophthalmologist, with a follow-up examination at least every few years for patients with no problems uncovered. Patients with diabetes should have annual eye examinations by an ophthalmologist to screen for proliferative diabetic retinopathy and also in light of the higher incidence of glaucoma.

[edit] Screening for Cognitive Impairment

Recent studies have suggested that approximately 10% of all individuals over the age of 65 have dementia. That prevalence may increase to almost 50% in individuals over the age of 85. The vast majority of these individuals have Alzheimer's disease or other primary degenerative dementia; however, a substantial minority has a vascular cause. Despite the staggering prevalence, in most instances mild degrees of cognitive impairment go unrecognized by physicians. Most likely this is because the usual screening questions about orientation to person, place, and time, although meaningful when they are abnormal, lack sufficient sensitivity to detect most cases.

A number of brief, simple instruments are available to screen for dementia. One of the most widely used and best validated is the Folstein Mini-Mental Status Examination (MMSE) (see Box 8-2 in Chapter 8 ). It consists of 11 questions and tasks with a total possible score of 30. Scores greater than 24 are considered normal, whereas scores less than 24 are indicative of dementia and usually warrant further evaluation. The MMSE is relatively insensitive to the early loss of higher executive function, especially in individuals with a high educational background. A “normal” score cutoff should be adjusted downward for individuals with little formal education (see Chapters 8 and 158 ).

The value of early detection of dementia lies in the fact that a small number (perhaps one in 10 in some instances) are the result of reversible causes (e.g., vitamin B₁₂ deficiency, thyroid disease) and may become irreversible if not recognized early. Vascular dementias may stabilize with aggressive control of cardiovascular risk factors, especially cigarette smoking and hypertension. The physician should always pay careful attention to potentially offending drugs, including alcohol. Even with an Alzheimer's-type dementia, in which no effective treatment of the underlying process exists, early diagnosis may lead to the prevention of unnecessary comorbidity and caregiver stress, through early referral to community-based services and home-care services. Symptomatic drug therapies are available that are most efficacious when employed in the earlier stages of disease.

[edit] Depression

Although no major authority recommends routine screening for depression in asymptomatic individuals, depression in the elderly may be quite subtle, making recognition and diagnosis difficult. It should be recognized that the elderly, particularly men, account for a disproportionate number of suicides, the majority of which are associated with depression and/or anxiety. Depression is commonly associated with early dementia, where it serves to increase the severity of symptoms, and, in general, is a common concomitant or cause of functional decline. Depression itself may present as cognitive decline, which may be erroneously attributed to a primary dementia. This pseudodementia, as it is commonly called, is an important cause of reversible dementia. Depression is extremely common following stroke in the elderly, in which case it may impede or prevent maximal recovery.

For all of these reasons, the physician should consider screening elderly patients for depressive symptoms. A simple, validated questionnaire (e.g., the geriatric depression scale) is useful in this regard. Once diagnosed, depression is readily treatable in the primary care setting, with referral or hospitalization reserved for patients who represent diagnostic or management dilemmas or who are actively suicidal. See Chapter 48 for a complete discussion of depression and its management.

[edit] Falls

Falls are a major cause of morbidity and mortality in community-dwelling elderly. One in three persons over the age of 75 falls each year, one fourth of those will suffer a serious injury, and one twentieth will suffer a fracture. The highest risk exists in patients with a history of falling. Other important risk factors include the use of sedative medication, cognitive impairment, polypharmacy, abnormalities of balance and gait, and urinary incontinence. Environmental hazards such as poor lighting, loose rugs, extension cords, and low furniture also frequently play a role.

Although there may be some overlap, fall syndromes should be distinguished from syncope, which has its own differential diagnosis and should prompt hospitalization in most instances. Physicians should ask older patients about falls routinely, and follow up positive responses with questions designed to accurately characterize the event, keeping in mind that patients often give nonspecific answers (e.g., “I must have slipped”).

The primary and secondary prevention of falls includes a routine history and physical, with attention paid to excluding previously unrecognized acute illness, and evaluating and simplifying the patient's medication regimen, eliminating sedatives whenever possible. Orthostatic hypotension, which can be caused by a variety of medications and medical conditions, should be sought out and offending agents or conditions removed or treated. Vision, hearing, and cognitive status should be evaluated, and intervention or referral carried out when appropriate. Physical therapy or an exercise program may be of benefit in improving strength, gait, and balance. Patients should be counseled about the value of improving lighting, removing low furniture, and taping down loose rugs and lamp cords. The physician should consider the potential benefit of a home visit by the physician, or a home evaluation from a certified home health agency (see Chapter 8 ).

[edit] Urinary Incontinence

The prevalence of urinary incontinence rises steadily with age, and women are more frequently affected than men. Urinary incontinence is the single most common factor precipitating institutionalization in the elderly. Other important impairments and morbidity that can result from established urinary incontinence include social isolation, depression, and falls.

Urinary incontinence is a distressing and embarrassing problem that frequently is not volunteered by the patient. The physician should routinely ask in a neutral and direct fashion about difficulty with bladder control, paying attention to timing (diurnal vs. nocturnal), amount voided, dribbling, and any association between coughing or laughing and dribbling. A history of urgency or dysuria is also important to consider. Often, the office history and physical examination lead to a diagnosis and effective intervention without referral. For a more detailed discussion of the evaluation and treatment of urinary incontinence, see Chapters 8 and 151 .

[edit] REFERENCES