The periodic health examination of older adults: the recommendations of the U.S. Preventive Services Task Force. Part II. Screening tests

Targeting Opportunities for Change: Mental Health Promotion in Primary Care

National policy directions currently provide an environment in which mental health promotion activities can be widely supported in health and related arenas. Several recent national reports have identified the importance of primary care, especially in general practice settings, as the principal point of entry to the Australian health care system. A broad overview of the current policy climate prefaces a discussion of the opportunities for mental health promotion in the primary care sector, focusing on general practice settings and using depression as an example. Implications and consequences related to training of the mental health workforce, with special reference to roles for psychologists are discussed. Finally, recommendations are made for future directions in mental health promotion and prevention research in primary care.

Falls in the community-dwelling older adult: a review for primary-care providers

Falls in the elderly are an important independent marker of frailty. Up to half of elderly people over 65 experience a fall every year. They are associated with high morbidity and mortality and are responsible for greater than 20 billion dollars a year in healthcare costs in the United States. This article presents a review and guide for the primary care provider of the predisposing and situational risk factors for falls; comprehensive assessment for screening and tailored intervention; and discussion of single and multicomponent measures for fall prevention and management in the older person living in the community. Interventions for the cognitively impaired and demented elderly will also be addressed.

Simple clinical tests may predict severe oropharyngeal dysphagia in Parkinson's disease

OBJECTIVE

To determine if simple screening tests can predict severe oropharyngeal dysphagia in subjects with Parkinson's disease.

METHODOLOGY

Forty-five subjects (26 females) of average age 75 (range: 65-94) who were classified as Modified Hoehn and Yahr stages 2 to 5 were enrolled. The presence of oropharyngeal dysphagia was assessed by a symptom questionnaire, 50 ml water swallowing test and videofluroscopic swallowing study.

RESULTS

Six of the subjects had severe oropharyngeal dysphagia in videofluroscopic swallowing study. Subsequent multivariate analysis showed that 3 factors could independently predict severe oropharyngeal dysphagia. These included higher Modified Hoehn and Yahr stage (P = 0.042), low Body mass index (P = 0.014), and increased difficulty in keeping food or drink in the mouth (P = 0.047). The regression model had a positive predictive power of 96% (sensitivity: 83.3%, specificity: 97.4%).

CONCLUSION

A combination of 3 simple clinical parameters may be useful for screening for severe oropharyngeal dysphagia as shown radiologically in subjects with Parkinson's disease.

Do the elderly benefit from annual physical examination? An example from Kaohsiung City, Taiwan

BACKGROUND

This study evaluates the impact of free annual health examinations on survival of elderly (> or =65 years of age) residents in Kaohsiung City, Taiwan.

METHODS

A stratified random sample scheme was used in each of the 11 districts of Kaohsiung City. A total of 1,193 elderly people were selected and interviewed in 1993; deaths and results of health check-ups were recorded through 1998.

RESULTS

While over 50% of the subjects received at least one health examination between 1993 and 1998, only 18% received three or more. Most (60%) subjects who received examinations in a given year also received examinations the subsequent year; most (over 70%) who did not receive examinations in a given year did not receive check-ups the following year. Cox proportional hazards model showed that those who utilized the examination service had better survival probability than those who did not, given the same age, sex, education, marital status, living arrangements, and number of chronic diseases at baseline: The relative risk (RR) of mortality for those who ever utilized the health examination service was 0.50 (P < 0.0001).

CONCLUSIONS

Elderly subjects who received annual health examinations had lower mortality than those who did not. This finding should be interpreted cautiously, however, as the difference in survival may reflect better general health behaviors among those who participated in the program.

The experiences of non-medical health professionals undertaking community-based health assessments for people aged 75 years and over

Our objective was to explore the perceptions of allied health professionals who conducted over 3000 home-based health assessments within the general-practice-dominated Australian primary healthcare system. A series of semistructured qualitative interviews were carried out within the Department of Veterans' Affairs 'Preventive Care Trial', where health assessments are undertaken by health professionals in the homes of participating veterans and war widows. Health professionals were employed within the Preventive Care Trial to conduct assessments in 10 areas of New South Wales and Queensland. Subjects were mainly registered nurses, but also included a social worker, an occupational therapist, a physiotherapist and a psychologist. The health professionals described positive attitudes towards the health assessments, and showed that they have the broad range of necessary personal and professional skills to undertake them. Home visits were seen as an essential component and the most useful aspects included direct observation of home safety and medications. This study demonstrates that health assessments for older people can be acceptably and competently undertaken by suitably qualified allied health professionals, and that an effective collaborative approach to patient care can be achieved through such a system.

Seniors' preferences for cancer screening and medication use based on absolute risk reduction

BACKGROUND

This study was conducted to determine the influence of patient perceptions of absolute risk on choices for cancer screening and use of medications to prevent heart attack, stroke, and hip fracture.

METHODS

At the end of routine office visits, we surveyed all eligible consecutive patients who visited four geriatricians in a Denver practice between November 8, 1993, and February 9, 1994.

RESULTS

We saw a total of 675 outpatients during the study period and completed the interview with 409 patients (75% female, mean age 81, 78% Caucasian). We found a strong correlation between (i) increased probability of detecting cancer and greater preference for cancer screening tests (p <.001) and (ii) increased probability of preventing disease (heart attack, stroke, or hip fracture) and greater preference for preventive medication (p <.0001). There was notable variability in seniors' preferences for a given therapy at each absolute risk threshold. For example, 15% of seniors did not think that highly effective, inexpensive medications to prevent heart attacks were worthwhile for them. At the other end of the spectrum, 22% of seniors felt that low-yield, costly medications to prevent heart attacks were worthwhile.

CONCLUSIONS

Seniors readily understand the probability of benefit expressed in terms of absolute risk reduction. Furthermore, probability of benefit strongly influences seniors' preferences for cancer screening and preventive medication use. Finally, there is variety in the thresholds of prevention at which individuals are willing to accept preventive treatment. The probability of benefit is an essential and useful element for seniors to make informed decisions about routine health services.

A thorough going over: evidence for health assessments for older persons

OBJECTIVE

To review published randomised controlled trials of health assessments for older people; consider the effects of assessments in maintaining health and quality of life for older people; and identify those factors associated with more successful health assessment programs.

METHODS

A systematic literature search and methodological review of published studies of health assessments for people aged 65 years and over, living in the community.

RESULTS

Twenty-one trials were identified. They were widely heterogeneous in terms of methodological quality, assessment content and outcome variables. While the studies' results are inconsistent, the majority of the more methodologically sound studies report improvements in health. The studies reporting positive health outcomes were not specifically targeted to particular groups at high need, but were applied to all people in the source population who had reached a set age, usually 75 plus. In the majority of studies reviewed, the assessments were conducted by non-medical personnel (nurse, lay interviewer/volunteer or office staff).

CONCLUSIONS

Health assessments have been associated with improved health outcomes for older people. An evidence base for specific components to be included in the assessments is yet to be derived.

IMPLICATIONS

In November 1999, new Medicare items to provide for health assessments for persons in Australia aged 75 years and over were introduced. The acceptability, adoption and effectiveness of these items needs careful monitoring.

Use of a short-form screening procedure to detect unrecognized functional disability in the hospitalized elderly

We performed an observational cohort study to test the ability of a short-form screening procedure to detect unrecognized functional disability, as well as its capacity to predict clinical outcome. This screening procedure was administered to 198 consecutive patients within 48 hours of admission. Clinical outcomes upon discharge from the acute care hospital and at 3 months were analyzed according to the number of functional disabilities present on admission. This brief test identified a mean of 1.8 and a median of 1 previously unrecognized functional disabilities per patient. The presence of two or more functional disabilities on admission (48% of the study population) was significantly associated with a negative outcome upon discharge (relative risk = 1.73; CI, 1.33-2.25; p = 0.0001) and at 3 months after discharge (relative risk = 1.34; CI, 1.10-1.64; p = 0.003) confirming the reliability of the short-form screening procedure.

Relationship of body mass index to subsequent mortality among seriously ill hospitalized patients. SUPPORT Investigators. The Study to Understand Prognoses and Preferences for Outcome and Risks of Treatments

OBJECTIVE

To determine if body mass Index (BMI = weight [kg]/height [m]2), predictive of mortality in longitudinal epidemiologic studies, was also predictive of mortality in a sample of seriously ill hospitalized subjects.

DESIGN

Prospective, multicenter study.

SETTING

Five tertiary care medical centers in the United States.

PATIENTS

Patients > or = 18 yrs of age who had one of nine illnesses of sufficient severity to anticipate a 6-month mortality rate of 50% were enrolled at five participating sites in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were asked their current height and weight as part of the demographic data. Stratifying body mass index by percentile rank (< or = 15, 15 to 85, and > or = 85th percentiles), risk ratios for mortality were calculated by Cox Proportional Hazards using the 15th to 85th percentile of body mass index as the reference group while controlling for multiple variables such as prior weight loss, albumin, and Acute Physiology Score. A body mass index in the < or = 15th percentile was associated with an excess risk of mortality (risk ratio = 1.23; p < .001) within 6 months. High body mass index (> or = 85th percentile) was not significantly related to risk of mortality.

CONCLUSIONS

Body mass index, a simple anthropometric measure of nutrition employed in community epidemiologic studies, has now been demonstrated to be a predictor of mortality in an acutely ill population of adults at five different tertiary centers. Even when controlling for multiple disease states and physiologic variables and removing from the analysis all patients with significant prior weight loss, a body mass index below the 15th percentile remained a significant and independent predictor of mortality. Examination of patient vs. proxy data did not change the results. Future studies examining variables predictive of mortality should include body mass index, even in acutely ill populations with a poor probability of survival.

Nutrition screening in old people: its place in a coherent practice of preventive health care

The central demographic reality of our times is the rapid aging of our society. Preventive nutritional and preventive health care of older people, therefore, are pressing issues that must be contended with. Several strategies for this are possible, including the broadcasting of general nutritional and health messages to the population, the inclusion of preventive nutrition and health as part of routine primary care, and nutrition screening: a process of self-identification by the older population in which they judge for themselves whether they are at nutritional risk and, if so, seek the care of professionals. This review focuses on some of the necessities for screening: sensitive, specific, and inexpensively applied screening devices; and explicit interventions that do not have major public health benefit for those who screen negative. Unfortunately, there is little evidence that screening is beneficial, nor have the benefits of this strategy been compared with its alternatives. Thus, the ethical imperative of screening has not been met: that because the activity is being promoted (it is not initiated by the public), its benefit must be conclusive.

Assessing physicians' and dentists' oral cancer knowledge, opinions and practices

Oral cancer is responsible for more than 8,000 deaths each year. This mortality may be attributed to lack of effective oral examinations by dental and medical primary care clinicians. This pilot project assessed the knowledge, opinions and practices of a group of Maryland physicians and dentists in oral cancer prevention, diagnosis and detection. Dentists performed more oral cancer examinations, although physicians saw more high-risk patients.

Nutrition and function: is there a relationship between body mass index and the functional capabilities of community-dwelling elderly?

OBJECTIVE

To determine if there is a relationship between body mass index and the ability to perform the usual activities of living in a sample of community-dwelling elderly.

DESIGN

Secondary data analysis of The National Health and Nutrition Examination Survey-I Epidemiologic Follow-up Study (1982-1984). Follow-up home interview of a population-based sample originally interviewed between 1971 and 1975 in the National Health and Nutrition Examination Survey-I (NHANES-I).

PARTICIPANTS

Survivors of the original NHANES-I cohort who were 65 years of age or older and who were living at home at the time of the second interview (n = 3061). Excluded were those who could not be found, refused participation, or were institutionalized (n = 220), and those without complete height and weight data (n = 194).

MAIN OUTCOME MEASURE

Functional status as measured by a 26-item battery.

RESULTS

Bivariate analysis revealed a greater risk for functional impairment for subjects with a low body mass index or a high body mass index. The greater the extreme of body mass index (either higher or lower), the greater the risk for functional impairment. Logistic regression analysis indicated that both high and low body mass index continued to be significantly related to functional status when 22 other potential confounders were included in the model.

CONCLUSION

The body mass index is related to the functional capabilities of community-dwelling elderly. The inclusion of this simple measurement in the comprehensive assessment of community-dwelling elderly is supported.

The relationship between dental utilization and preventive participation among a well-elderly sample

Previous studies have shown that dental utilization by older people is lower than for the general population. This study hypothesizes that an elder's tendency toward participating in preventive health activities may be an important factor in explaining the likelihood of accessing the dentist. Subjects included 1,911 older individuals who enrolled in the UCLA Medicare Screening and Health Promotion Trial. All were interviewed about their utilization of preventive health services and participation in preventive behaviors. A recent dental visit was positively associated with all sociodemographic variables examined except age and sex. It was also related to health status questions and utilization of the preventive health services and health behaviors studied. Logistic regression analysis showed that both summary preventive health behavior and preventive service utilization variables were important factors in explaining a recent dental visit (model chi-square = 221.4, P = .001) along with income, not having a removable prosthesis, and perceiving the need for dental care. This study showed that dental utilization is related to older people's participation in other preventive activities. When in contact with older people, health care professionals should consider current oral and general preventive health status and encourage appropriate referral for preventive activities.

Common gynecologic problems after age 75

Management of gynecologic problems in women aged 75 and over can be challenging. Appropriate examination and evaluation differs from that for younger women, and these patients are often poor surgical candidates. The most common presenting conditions include stress incontinence, atrophic changes of the vulva and vagina, and pelvic relaxation with uterine prolapse. Several techniques for nonsurgical management are available, including topical and systemic drug therapy and use of products and aids that increase comfort and encourage independence.

Mammography and Papanicolaou smear use by elderly poor black women. The Harlem Study Team

OBJECTIVE

To describe factors related to the use of mammography and Papanicolaou smears in low-income women aged 65 or more years to guide development of future interventions.

DESIGN

A cross-sectional survey.

SETTING AND PATIENTS

Elderly Black women attending a public hospital medical clinic.

MEASUREMENTS

Information obtained in a face-to-face interview of a random sample of patients.

RESULTS

Four-hundred and forty-five women (94%) consented to be interviewed; 74% reported a mammogram, and 85% reported a Papanicolaou smear in the past, although these early-detection tests were not obtained with any regularity after age 65. Concordance between self-reported screening use and blind chart review was more than 90%. The major reasons for non-use of both screening tests were that a physician hadn't recommended them or that the women didn't know they needed them. Levels of knowledge about breast and cervix cancer were low; 68% believed bumping or bruising the breast caused cancer, and only 25% knew that cancer risk increased with advancing age. In logistic regression models, health status, provider type, perceived benefit, life satisfaction, and knowledge of test intervals were each significantly associated with mammogram use. Age, health status, education, perceived susceptibility and benefit, life satisfaction, and knowledge of test intervals were independently related to Pap use (P < .05).

CONCLUSION

This study illustrates that elderly, poor, minority women who are regular health-care users do use mammography and Pap smear screening services. Incorporating screening into routine primary care and physician and patient education could enhance the use of early cancer detection procedures in this age group.

Optimal care of older women. An opportunity for both prevention and treatment

As the number of older women and their average life expectancy increase, physicians will need to focus as much on providing preventive, health-promoting care as on treating disease. Drs South-Paul and Woodson present a guide for multidimensional evaluation of asymptomatic older women that can serve as a framework for designing individualized care.

Blood lipid distributions in older persons. Prevalence and correlates of hyperlipidemia

Distributions of blood total cholesterol, triglyceride, low-density-lipoprotein (LDL) cholesterol, and high-density-lipoprotein (HDL) cholesterol levels are presented for a geographically defined cohort of rural elderly Iowans, 71 to 102 years old. Cross-sectionally, women had higher levels of total and LDL cholesterol than men did, levels that declined with increasing age. Mean HDL cholesterol levels were also higher in women than in men, but remained relatively constant across the age range. Age- and sex-specific total, LDL, and HDL cholesterol levels were lower among participants residing in long-term-care facilities. HDL but not total cholesterol levels were lower in cigarette smokers and those with chronic illnesses, physical dependence, and poorer performance on physical function tests, and higher among those consuming alcohol. If subjected to the screening guidelines of the National Cholesterol Education Program, a majority of this population, having total cholesterol levels of 5.2 mmol/L (200 mg/dL) or higher, would require further evaluation for possible hyperlipidemia.

Routine laboratory assessment of nursing home patients

Little is known about protocols for routine laboratory testing in nursing homes. To determine what laboratory protocols are employed by community nursing homes, directors of nursing service in the 73 long-term-care facilities in Portland, Oregon were surveyed. One-hundred percent responded, and 56% reported having laboratory testing protocols. Ninety percent of protocols employed screening tests, and 88% employed monitoring tests, but content varied widely. Although physicians are ultimately responsible for ordering laboratory tests, protocols were derived from various sources including nursing staff, pharmacy and laboratory consultants, and Department of Health and Human Service guidelines. It is recommended that physicians take a leadership role in helping nursing homes develop clinically useful, cost-effective testing strategies.