SOAP. Healthy Living for Adult-Geriatric Patients

Health Maintenance During the Life Span

Cheryl A. Glass

See Section III: Patient Teaching Guide “Health Maintenance During the Life Span.” Patient teaching guides may be downloaded by the practitioner, filled according to the patient’s evaluation and needs, and given to the patient.

Adult Risk Assessment Form

Cheryl A. Glass

The Adult Risk Assessment Form (Exhibit 2.1) should be used for all adult patients to evaluate a patient’s risk for particular diseases. The practitioner should interview the patient, assessing for the risk factors listed on the Risk Assessment Form. The family history of first-degree relatives (parents, siblings, and children) should also be discussed, because many diseases are related to genetic factors. Keep a copy of the Risk Assessment Form in the front of the patient’s chart, and update yearly or as needed. When complete, this tool can guide the practitioner in determining the assessment needs of each patient. If using electronic medical records, a special section should be identified for risk assessment.

Adult Preventive Healthcare

Cheryl A. Glass

Exhibits 2.2 and 2.3 help the practitioner identify changes in the adult patient’s risk factor status, make recommendations for health maintenance (e.g., immunizations, laboratory work, physical exams), and educate patients in prevention. The guide can be used as a quick reference for the practitioner to evaluate the patient’s adherence to preventive measures. Keep a copy of this flow sheet and guide in the front of the patient’s chart where they can be reviewed routinely and updated as necessary. If using electronic medical records, a special section should be identified as routine health maintenance.

Adult/Geriatric Screening Recommendations

Cheryl A. Glass

Health promotion includes the utilization of preventative screen testing. Multiple guidelines are available for clinicians to utilize for guidance and discussion of recommendations with patients. Professional societies, the U.S. Public Health Service, and other organizations evaluate the strength of evidence and the weight of clinical research, statistical analysis, and the risk and benefits of testing to make recommendations for screening. Most of the recommendations for this section are from the U.S. Preventive Services Task Force (USPSTF) guidelines.

Eligibility and Medicare coverage for screening are summarized in Table 2.1.

EXHIBIT 2.1 Adult Risk Assessment Form

Name ____________________________ DOB ____________________________ Chart # ____________________________

Allergies __________________________________________________

Occupation __________________________________________________

Assess the patient for the following personal risk factors:

A.Coronary heart disease:

1.High-fat/high-cholesterol diet

2.Obesity

3.Elevated cholesterol level

4.Stroke

5.Hypertension

6.Tobacco use

B.Lung cancer:

1.High-fat/high-cholesterol diet

2.Tobacco use

C.Cervical cancer:

1.Early age of first intercourse

2.Multiple sexual partners

3.History of HPV

D.Breast cancer:

1.Nulliparous

2.Primigravida after age 35

3.High-fat diet

E.Colon cancer:

1.History of polyps

2.High-fat diet

F.Osteoporosis:

1.Less than 1 g of calcium per day

2.History of tobacco or alcohol use

3.Sedentary lifestyle

4.Thin, Caucasian

5.Female gender

G.Glaucoma/visual impairment:

1.Family history of glaucoma

2.Diabetes mellitus

H.STIs/HIV:

1.Alcohol and drug use or abuse

2.Multiple sexual partners

3.Homosexual or bisexual partner

4.History of intravenous drug use/needle sharing

5.History of blood transfusion

6.Exposed to or past history of STI

7.Exchanging sex for drugs or money

I.Substance abuse:

1.Alcohol or drug use history including street drugs and opioids

2.Family history of substance abuse

3.Stress or poor coping mechanisms

4.Administer the CAGE Assessment:

Have you ever tried to Cut down on your alcohol/drug use?

Do you get Annoyed if someone mentions your use is a problem?

Do you ever feel Guilty about your use?

Do you ever have an Eye-opener first thing in the morning after you have been drinking or using the night before?

J.Accidents and suicide:

1.Previous suicide attempt

2.Family history of suicide

3.Alcohol use

4.Substance use

5.History of depression

6.High-stress or hot-reactor personality

7.Male gender

8.Poor coping mechanisms or stress

K.Safety:

1.Does not use seat belt or car seat

2.Drinks and drives

3.Drives over the speed limit

4.Does not wear safety helmet if driving motorcycle

5.Inadequate number of smoke detectors or none in the home

CAD, coronary artery disease; DM, diabetes mellitus; HPV, human papilloma virus; STI, sexually transmitted infection.

EXHIBIT 2.2 Adult Preventive Healthcare Flow Sheet

Assess patients for the following behaviors:

Patients should be educated about any behavior modifications that can reduce their risk factors for health problems. The practitioner should note the date as well as the type of counseling given to a patient.

HepB, hepatitis B; MMR, measles, mumps, rubella; TB, tuberculosis.

EXHIBIT 2.3 Adult Health Maintenance Guide

Name ____________________________ DOB ____________________________ Chart# ____________________________

Allergies ____________________________ Occupation ____________________________

The following tests should be performed according to the individual patient’s risk factors as part of preventive healthcar should fill in the date and result of each test and highlight any remarkable results.

BMI, body mass index; BP, blood pressure; PSA, prostate-specific antigen; STI, sexually transmitted infection; TSH, thyroid-stimulating hormone.

TABLE 2.1 Medicare Coverage and Eligibility for Screening: Current as of 2018

	•Complete an HRA. •Review medical and family history. •Develop or update the list of current providers and prescriptions. •Measure height, weight, blood pressure, and other routine measurements. •Evaluate cognitive impairment. •Personalize health advice. •List risk factors and treatment options. •Develop screening schedule for appropriate preventive services.
AAA screening	One-time AAA ultrasound if patient meets eligibility requirements. A referral is required. Risk factors for eligibility: •Family history of AAA. •Male age 65–75 years and have smoked at least 100 cigarettes/lifetime.
Bone mass measurement	Covered screen once every 24 months for people who meet the eligibility criteria: •Women whose doctor determines both of these (based on medical history and other findings): Estro-deficient. At risk for osteoporosis. X-rays showing possible osteoporosis, osteopenia, or vertebral fractures. Person taking prednisone or steroid-type drugs or is planning to begin this treatment. Person who has been diagnosed with primary hyperparathyroidism. Person being monitored to evaluate the osteoporosis drug therapy is effective. Covered more often if medically necessary.
Alcohol misuse screenings and counseling	Covered screen once per year for people who meet the eligibility criteria: •Adults with Part B (including pregnant women). Use alcohol. Do not meet the medical criteria for alcohol dependence. •Four brief face-to-face counseling sessions per year if these apply: Primary care doctor determines alcohol misuse. Competent and alert during counseling. •Counseling must be provided: By a qualified primary care doctor or other primary care practitioner. In a primary care setting.
Cardiovascular disease (behavioral therapy)	One visit per year in PCP office or primary care clinic: •Check blood pressure. •Discuss aspirin use (if appropriate). •Discuss dietary information.
Cardiovascular disease screening	Screening blood tests every 5 years: •Cholesterol. •Lipids. •Triglycerides.
Cervical and vaginal cancer screenings	Part B covers Pap tests, pelvic exams, and clinical breast exams: •Once every 24 months for all women. •Once every 12 months if one of these apply: High risk for cervical or vaginal cancer. Childbearing age and have had an abnormal Pap test in past 36 months.
Colorectal screening	FOBT: •Coverage with a referral from a physician, physician assistant, nurse practitioner, or clinical nurse specialist. Multitarget stool DNA test: •Covered once every 3 years if all conditions are met: 50–85 years of age. No signs or symptoms of colorectal disease including, but not limited to: –Lower gastrointestinal pain. –Blood in stool. –Positive guaiac fecal occult blood test. –Fecal immunochemical test. At average risk for developing colorectal cancer, meaning: –No personal history of the following: Adenomatous polyps. Previous colorectal cancer. Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis. –No family history of the following: Colorectal cancers or adenomatous polyps. Familial adenomatous polyposis. Hereditary nonpolyposis colorectal cancer. Screening flexible sigmoidoscopy: •Once every 48 months for most people 50 years or older. •If not high risk, is covered 120 months after a previous screening colonoscopy. Screening colonoscopy: •Once every 24 months if at high risk for colorectal cancer. •If not high risk, is covered once every 120 months, or 48 months after a previous flexible sigmoidoscopy. A screening colonoscopy can become a diagnostic colonoscopy when: •Results in the biopsy or removal of a lesion or growth.

	•The biopsy or removal happens during the same visit as the screening colonoscopy. Barium enema: •When utilized instead of a flexible sigmoidoscopy or colonoscopy: Coverage every 48 months if 50 years or over. Coverage every 24 months and are at high risk for colorectal cancer.
Dental	Medicare does not cover routine dental care or dental procedures such as cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices.
Depression screening	Medicare covers one depression screening per year. The screening must be done in a primary care setting that can provide follow-up treatment and/or referrals.
Diabetes screening	Medicare covers screening to test for diabetes: •Based on the screening test, may be eligible for two diabetes screenings each year. •Screenings covered if any of the following risk factors exist: Diagnosed with prediabetes. Hypertension. History of abnormal cholesterol and triglycerides. Obesity. History of high glucose. •Covers these tests if two or more of these apply: Age 65 or older. Overweight. Family history of diabetes (parents, brothers, sisters). History of gestational diabetes or the delivery of a baby weighing more than 9 pounds. If covered with Medicare Part B and have prediabetes, may qualify for diabetes prevention program services to help make health behavior changes that can prevent or delay the onset of diabetes. The program begins with at least 16 core sessions over a 6-month period, which are offered in a group setting. After the core sessions, additional monthly sessions in the diabetes prevention sessions include the following: •Tips on how to get more exercise. •Strategies for weight control. •Support from people with similar goals and challenges. •A lifestyle coach, specially trained in motivation.
Diabetes self-management training	Outpatient diabetes self-management training (DSMT) to teach coping and management of diabetes: •May cover up to 10 hours of initial DSMT. This training may include 1 hour of individual training and 9 hours of group training. •May also qualify for up to 2 hours of follow-up training each year if it takes place in a calendar year after the year of initial training. •Training includes the following: Tips for eating healthy, being active, taking drugs, and reducing risks. •Must have a written order from a doctor or other healthcare provider for certain people with Part B who are at risk for complications from diabetes. •Some exceptions apply: Group sessions are not available or if the doctor or qualified nondoctor practitioner notes special needs that would be better met in individual training sessions. Living in a rural area, may get DSMT services from a practitioner, such as a registered dietitian in a different location through telehealth.
Hepatitis C screening test	Covers one hepatitis C screening test if a primary care doctor or practitioner orders it: •Also covers yearly repeat screening for certain people at high risk who meet one of these conditions: High risk because they use or used illicit injection drugs. Had a blood transfusion before 1992: Born between 1945–1965.
HIV screening	Voluntary HIV screenings, one test once every 12 months: •Covered for people who meet the criteria. •15–65 years old. •Younger than 15 or older than 65, and at increased risk. •Pregnant: Covered up to three times during a pregnancy. Interval testing during pregnancy is not defined by CMS.
Immunizations	Flu shot: •Normally covers one flu shot per flu season given in the fall or winter. HepB: •People at high or medium risk for HepB: Some risk factors noted as increased risk defined by Medicare include hemophilia, ESRD, diabetes, healthcare workers that have frequent contact with blood or bodily fluids, and other factors that increase risk for HepB (check with doctor to see if at high or medium risk). Pneumococcal shot: •One pneumococcal shot to prevent infections. •Part B also covers a different second shot if it is given 1 year (or later) after the first shot.

	•Discuss with the doctor or other healthcare provider to evaluate need for one or both shots.
Lung cancer screening	A lung cancer screening with LDCT once per year for patients who meet all of the following conditions: •Age 55–77. •Asymptomatic (no signs or symptoms of lung cancer). •Either a current smoker or have quit smoking within the last 15 years. •Tobacco smoking of at least 30 “pack years” (an average of one pack a day for 30 years). •Written order from their physician. •Before the first lung cancer screening, an appointment needs to be scheduled to: Discuss the benefits and risks of lung cancer screening. Decide whether lung cancer screening is right for the patient.
Mammography (medical)	Screening mammogram once every 12 months (11 full months must have passed since the last screening). Diagnostic mammogram when medically necessary: •Women with Medicare 40 years of age or older are covered. •Women with Medicare 35–39 years of age can get one baseline mammogram.
Nutrition therapy services	MNT services and certain related services: •A registered dietitian or nutrition professional who meets certain requirements can provide these services. •Only a doctor can refer for these services. •MNT services may include the following: An initial nutrition and lifestyle assessment. Individual and/or group nutrition therapy services. Follow-up visits to check on progress managing diet. •In a rural area, MNT may be provided through telehealth. A registered dietitian or other nutrition profession, in a different location, would provide the service. •Medicare covers MNT as part of overall dialysis care if dialysis is done in a dialysis facility. •Eligibility includes people with Part B who meet at least one of these conditions: Have diabetes. Have kidney disease. Have had a kidney transplant in the last 36 months.
Obesity screening and counseling	Medicare covers behavioral counseling for weight loss. Counseling may be covered if given in a primary care setting (such as a doctor’s office). •The counseling is required in a primary care setting so that it can be coordinated with other care and a personalized prevention plan. •All people with a BMI of 30 or more are covered.
Prostate cancer screening	All men older than 50 (beginning the day after their 50th birthday). Digital rectal examination: •Once every 12 months. PSA test: •Once every 12 months.
STIs screening and counseling	Screening for chlamydia, gonorrhea, syphilis, and HepB: •Once every 12 months. •At certain times during pregnancy. Medicare also covers up to two individual 20- to 30-minute, face-to-face, high-intensity behavioral counseling sessions each year for sexually active adolescents and adults at increased risk for STIs if referred by a doctor.
Smoking and tobacco use cessation	Counseling for up to eight face-to-face visits in a 12-month period performed by a qualified doctor or other Medicare-recognized practitioner Eligibility for counseling includes all people with Part B who use tobacco.
Vision	Medicare does not cover routine eye examinations for eyeglasses or contact lenses. AMD testing is covered. Vision screen for glaucoma: •Glaucoma test every 12 months for people at high risk for glaucoma: Diabetes. Family history of glaucoma. African Americans and those 50 years or older. Hispanic Americans and those 65 years or older. Vision screen for retinopathy: •Yearly exam for diabetic retinopathy. •People on Medicare who have diabetes.

Note: Consult the Medicare website for full coverage information and costs: https://www.medicare.gov/coverage/preventive-and-screening-services.html. AAA, abdominal aortic aneurysm; AMD, age-related macular degeneration; BMI, body mass index; CMS, Centers for Medicare and Medicaid Services; DSMT, diabetes self-management training; ESRD, end-stage renal disease; FOBT, fecal occult blood test; HepB, hepatitis B; HRA, Health Risk Assessment; LDCT, low-dose computed tomography; MNT, medical nutrition therapy; PCP, pri- mary care physician; PSA, prostate-specific antigen; STI, sexually transmitted infection.

Note: Consult the Medicare website for full coverage information and costs: https://www.medicare.gov/coverage/preventive-and-screening-services.html.

AAA, abdominal aortic aneurysm; AMD, age-related macular degeneration; BMI, body mass index; CMS, Centers for Medicare and Medicaid Services; DSMT, diabetes self-management training; ESRD, end-stage renal disease; FOBT, fecal occult blood test; HepB, hepatitis B; HRA, Health Risk Assessment; LDCT, low-dose computed tomography; MNT, medical nutrition therapy; PCP, primary care physician; PSA, prostate-specific antigen; STI, sexually transmitted infection.

Abdominal Aortic Aneurysm

Cheryl A. Glass

The Centers for Disease Control and Prevention (CDC) notes abdominal aortic aneurysms (AAAs) were the primary cause of death for greater than 10,000 persons in 2014. The main risk factors for development of AAAs are age, gender, smoking, and family history. About two-thirds of people who have an aortic dissection are male. Older males who have smoked are at the highest risk of developing an AAA. Dissections and ruptures are the cause of most deaths from aortic aneurysms. An AAA is often asymptomatic; however, the symptoms may include a sharp, sudden pain in the chest; throbbing or deep pain in the back or side and/or pain in the buttocks, groin, or legs; trouble breathing or swallowing; or syncope. Nearly two-thirds of aneurysms leading to surgery were detected as incidental findings on imaging studies performed for other indications. On physical examination a pulsatile mass in the epigastrium where the aorta bifurcates at the umbilicus may be palpated.

There are several types of aneurysm: thoracic aneurysms, abdominal aneurysms, peripheral aneurysms, and those that occur in the brain, which may cause a stroke. An AAA is an enlarged ballooning area that is more than 50% of the normal diameter of the aorta. The U.S. Preventive Services Task Force (USPSTF) notes that people who are screened are about twice as likely to have AAA surgery within 3 to 5 years compared with people who are not screened. The 2014 USPSTF guideline on Abdominal Aortic Aneurysm: Primary Care Screening is currently being updated. The current 2014 recommendations for AAA screening include the following:

A.Men ages 65 to 75 years who have ever smoked (100 cigarettes in a lifetime) should have a one-time ultrasound screening for AAA even if they are asymptomatic.

B.Men ages 65 to 75 years who have never smoked can be selectively offered screening by clinicians rather than routinely screening all men in this group. Screening should be based on medical history, family history, other risk factors, and patient preferences.

C.The current evidence is insufficient to assess the balance benefits and harms for the USPSTF to recommend that women ages 65 to 75 who have ever smoked be screened for AAA.

D.The USPSTF recommends that women who smoke or have never smoked should not undergo AAA screening. AAA is uncommon in older women and is very rare in women who have never smoked. The Society for Vascular Surgery (SVS) 2018 guidelines recommends men and women older than 75 years with a history of tobacco use who are in otherwise good health and have not previously been screened with ultrasound have a one-time ultrasound screen for AAA.

E.The ultrasound is the gold standard modality for screening. CT scans are not recommended for first-line screening because of high cost and radiation exposure

F.Aneurysm size:

1.Small aneurysms have a diameter of less than 4.0 cm.

2.Medium aneurysms have a diameter between 4.0 and 5.5 cm:

a.The SVS guidelines recommend observation for asymptomatic AAA less than 5.5 mg in diameter.

3.Large aneurysms have a diameter ≥5.5 cm:

a.For asymptomatic patients, the risk of AAA rupture generally does not exceed the risk associated with elective AAA repair until aneurysm diameter exceeds 5.5 cm.

4.Very large aneurysms have a diameter ≥6.0 cm.

G.Management consists of ongoing clinical evaluation and AAA surveillance and risk modification. Aneurysm surveillance from the SVS supports the following surveillance intervals:

1.Initial ultrasound screening for aortic diameter greater than 2.5 cm but less than 3.0, rescreening after 10 years.

2.For AAA 3.0 to 3.9 cm, imaging at 3-year intervals.

3.For AAA 4.0 to 4.9 cm, imaging at 12-month intervals.

4.For AAA 5.0 to 5.4 cm, imaging at 6-month intervals.

H.Aneurysm diameter is the strongest predictor of aneurysm rupture, with risk increasing markedly at aneurysm diameters greater than 5.5 cm. Rapid expansion, which is thought to increase the risk for rupture, is defined as an increase in maximal aortic diameter ≥5 mm over a 6-month period of time or greater than 10 mm over 1 year, using the same radiographic method of measurement.

I.AAA surgical repair:

1.The decision for elective repair of asymptomatic AAA relies primarily on determining rupture risk based upon aneurysm diameter greater than 5.5 cm. However, the diameter threshold for repair is not absolute. An elective AAA repair should also take into account the natural history of AAA and factors that increase the risk for aneurysm expansion or rupture.

2.Repair is indicated for patients with AAA who are symptomatic (tenderness or abdominal or back pain, evidence for embolization, rupture), have an AAA ≥5.5 cm, or an AAA that has expanded more than 0.5 cm within a 6-month interval.

3.There are two types of surgical repair:

a.Open surgical repair is the only proven intervention that has decreased AAA mortality. The open surgical repair of a large AAA has a mortality rate of 4% to 5% with nearly one-third having pulmonary and cardiac complications.

b.Endovascular aneurysm repair (EVAR) with stent grafts is the surgical procedure alternative to open repair. A late conversion to an open repair may be required. The overall complication rate for EVAR, including access-related issues, is approximately 10%.

4.An individualized approach to the patient when choosing between open and EVAR repair needs to take into account the patient’s age, risk factors for perioperative morbidity and mortality, anatomic factors, and experience of the surgeon.

Bone Mass Density Measurement for Osteoporosis

Cheryl A. Glass

Osteoporosis and low bone mass are currently estimated to be a major public health threat for almost 44 million U.S. women and men age 50 and older. The incidence of fragility fractures increases exponentially with age, although the increase begins approximately 10 years later in men. However, the mortality rate associated with hip fractures, as well as vertebral and other major fractures, is higher in men than in women. Falls cause nearly 90% of osteoporotic fractures. Elderly patients have increased susceptibility to fractures because of other medical problems, side effects of medications, and the elderly’s tendency to fall. Falls cause nearly 90% of osteoporotic fractures. Fractures may cause chronic pain and disability and affect the functional ability and quality of life: mortality and morbidity are highest with a hip fracture. For an in-depth review of osteoporosis, refer to section Osteoporosis/Kyphosis/Fracture of Chapter 22.

The fracture risk assessment tool (FRAX) calculates absolute fracture risk or estimates the probability of fracture. The algorithms from the FRAX calculate a probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture). The FRAX assessment includes questions about age, smoking, family history of hip fracture, long-term glucocorticoid use, and low body weight.

The FRAX score is used to drive decisions for testing and prescribing osteoporosis medications.

The Foundation for Osteoporosis Research and Education (FORE) FRAX score 10-Year Fracture Risk Calculator is available at riskcalculator.fore.org or is available at the University of Sheffield, Great Britain website at www.sheffield.ac.uk/FRAX. The National Osteoporosis Foundation (NOF) Clinician’s Guide to Prevention and Treatment of Osteoporosis is available at https://my.nof.org/file/bonesource/Clinicians-Guide.pdf.

Screening through the identification of risk factors does not diagnose osteoporosis but identifies people who require further evaluation.

Bone mass measurement screening is done through several tests.

A.A standard x-ray is inadequate for screening for osteoporosis.

B.The gold standard test for the measurement of bone mineral density (BMD) is the use of the central dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine.

1.The central DXA of the radius bone and peripheral bone density of the heel or another bone may be required for the morbidly obese patient.

C.The quantitative ultrasonography (QUS) of the calcaneus is also utilized for measurement:

1.The measurement cutoffs of the QUS and the DXA are not interchangeable.

2.A limitation of ultrasound is that it does not reliably exclude or confirm DXA-determined osteoporosis.

3.Because of limited precision and slow rate of change of bone mass at peripheral sites, the quantitative heel ultrasound cannot be reliably used to follow patients who are treated for osteoporosis.

4.An individual with a high-risk ultrasound finding needs a confirmatory DXA to determine the need for treatment based on established guidelines and as a baseline for monitoring therapy.

D.The peripheral quantitative CT (pQCT) is available but is not recommended for screening. QCT measures volumetric bone density of the spine and hip and can analyze cortical and trabecular bone separately. The application of T-scores to predict the risk of fracture has not been validated with QCT. Additionally, the test is more costly and results in greater exposure to radiation than DXA.

The recommendations for who to screen and screening intervals of 1 to 2 years vary by different organizations, including the NOF, the World Health Organization, and the American College of Obstetricians and Gynecologists (ACOG). The U.S. Preventive Services Task Force (USPSTF) guideline on Osteoporosis Screening is currently being updated; the USPSTF guideline is current as of July 2015. The USPSTF recommends screening for osteoporosis by gender and age:

A.Women:

1.Age 65 years or older.

2.The USPSTF does not define the upper age limit for screening in women because the risk of fractures increases in age.

3.According to the draft USPSTF recommendation, risk factors should be considered in the decision about whether to screen women under the age of 65; these include parental history of hip fracture, smoking, excess alcohol consumption, low body weight, and menopausal status. The NOF, International Society for Clinical Densitometry (ISCD), Endocrine Society, and Canadian Osteoporosis Society recommend bone density testing for women older than 50 years with any clinical risk factors for fractures.

B.Men:

1.Routine screening is currently a widespread practice.

2.Current evidence is insufficient to assess the benefits versus harms of BMD screening for osteoporosis in men. The USPSTF found inadequate evidence that drug therapies reduce the risk of fracture in men who have no previous osteoporotic fracture.

The NOF, ISCD, Endocrine Society, and Canadian Osteoporosis Society recommend bone density testing for all men age 70 years or older and for men age 50 to 69 years based on their risk-factor profile.

Cardiovascular Disease and Cardiac Screening (Cardiac Calcium Score)

Cheryl A. Glass

The U.S. Preventive Services Task Force (USPSTF) has multiple screening and prevention recommendations for cardiac and cardiovascular disease (CVD). Refer to Chapter 13 for an in-depth review of cardiac conditions.

A.Screening recommendations:

1.Screen for high blood pressure in adults age 18 years and older:

a.The recommendation includes measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

b.Annual screening for adults age 40 years or older and for those who are at increased risk for high blood pressure. Persons at increased risk include those who have high normal blood pressure (130–139/85–89 mmHg), those who are overweight or obese, and African Americans.

c.Adults age 18 to 39 years with normal blood pressure (<130/85 mmHg) who do not have other risk factors should be rescreened every 3 to 5 years. The USPSTF recommends rescreening with properly measured office blood pressure and, if blood pressure is elevated, confirming the diagnosis of hypertension with ambulatory blood pressure measurement (ABPM).

The USPSTF recommends ABPM as the reference standard for confirming the diagnosis of hypertension (HTN). Ambulatory blood pressure (BP) monitoring devices record blood pressure at regular intervals over 12 to 24 hours while the patient goes about his or her normal activities and while sleeping. Elevated ambulatory systolic BP is consistently and significantly associated with increased risk for fatal and nonfatal stroke and cardiovascular (CV) events, independent of office BP. Ambulatory BP monitoring can be performed every year in high-risk persons and every 3 to 5 years in those at low risk (adults age 18–39 years with no risk factors).

2.There are no gender-specific recommendations for screening for lipid disorders. The age specifics for screening are:

a.Adults age 40 to 75 years with no history of CVD and have one or more risk factors for CVD. Risk factors include dyslipidemia, diabetes, high blood pressure, and smoking:

i.10-year cardiovascular event risk ≥10%: Low-to moderate-dose statins are recommended.

ii.10-year cardiovascular event risk 7.5% to 10%: Recommendation is for selectively offering treatment using an individualized approach.

b.Adults age 76 years and older with no history of CVD—there is insufficient evidence to make a recommendation.

3.Screen for coronary heart disease (CHD) with echocardiogram (ECG): The USPSTF found inadequate evidence to determine whether adding resting or exercise ECG to conventional risk factor assessment leads to improved risk stratification of persons to inform treatment decisions.

a.Adults at low risk of CVD events: USPSTF recommends against screening with resting or exercise ECG for the prediction of CVD events in asymptomatic adults at low risk for CVD events.

b.Adults at intermediate or high risk of CVD events: Currently insufficient evidence to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk for CHD events.

4.The current evidence is insufficient to assess the benefits and harms of screening for peripheral artery disease and CVD risk assessment with the ankle-brachial index (ABI) in adults:

a.There are no studies that provide evidence about the intervals for screening for peripheral arterial disease (PAD) with the ABI.

b.Evidence shows that low-dose aspirin treatment in asymptomatic patients with low ABI does not improve health outcomes and may increase bleeding.

c.There are no trials that provide evidence on other interventions to reduce CVD events or interventions that might delay the onset of lower-extremity symptoms.

5.USPSTF recommends against screening for asymptomatic carotid artery stenosis in the general adult population.

6.The evidence is insufficient to assess the balance of benefits and harms of using nontraditional risk factors to screen asymptomatic men and women with no history of CHD to prevent CHD events. The nontraditional risk factors included in this recommendation include the following:

a.High-sensitivity C-reactive protein (hs-CRP).

b.ABI.

c.Leukocyte count.

d.Fasting blood glucose level.

e.Periodontal disease.

f.Carotid intima media thickness (CIMT).

g.Coronary artery calcification (CAC) score on electron-beam CT (EBCT).

h.Homocysteine level.

i.Lipoprotein(a) level.

B.The American College of Cardiology (ACC) notes the CAC, a high-tech screen for CVD, is considered a second-tier assessment technique. Cost remains one concern as well as the radiation risk. It is a good predictor of future cardiac disease events, which includes stroke. The calcium burden measured by CAC probably equals about one-fifth of the total atherosclerosis burden. The ACC/American Heart Association (AHA) guideline on the Assessment of Cardiovascular Risk states that If, after quantitative risk assessment, a risk-based treatment decision is uncertain, assessment of ≥1 of the following—family history, hs-CRP, CAC score, or ABI—may be considered to inform treatment decision making.

C.Prevention recommendations with aspirin:

The magnitude of the cardiovascular risk reduction with aspirin use depends on an individual’s initial risk for CVD events. Risk assessment for CVD should include evaluation of the following risk factors: age, sex, race/ethnicity, total cholesterol level, high-density lipoprotein (HDL) cholesterol level, systolic blood pressure, hypertension treatment, diabetes, and smoking. An online version of the ACC/AHA risk calculator can be found at tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate.

1.Recommendations for the use of aspirin for the primary prevention of CVD and colorectal cancer (CRC) are noted in Table 2.2:

a.The USPSTF concludes that the evidence on aspirin use in adults younger than 50 years or older than 69 years is insufficient and the balance of benefits and harms cannot be determined.

b.In adults age 50 to 69 years who are at increased CVD risk, the benefits of aspirin use include prevention of myocardial infarction (MI) and ischemic stroke and, with long-term use, reduced incidence of CRC. Aspirin use may also result in small to moderate harms, including gastrointestinal (GI) bleeding and hemorrhagic stroke.

c.The USPSTF concludes with moderate certainty that the benefit of aspirin use for the primary prevention of CVD events, combined with the reduced incidence of CRC, outweighs the increased risk for bleeding by a moderate amount in adults age 50 to 59 years who have a 10-year CVD risk of 10% or greater.

d.The USPSTF concludes with moderate certainty that the benefit of aspirin use for the primary prevention of CVD events, combined with the reduced incidence of CRC, outweighs the

increased risk for bleeding by a small amount in adults age 60 to 69 years who have a 10-year CVD risk of 10% or greater.

e.Harms of aspirin use: The USPSTF found adequate evidence that aspirin use in adults increases the risk for GI bleeding and hemorrhagic stroke. The USPSTF determined that the harms vary but are small in adults age 59 years or younger and small to moderate in adults age 60 to 69 years. The USPSTF found inadequate evidence to determine the harms of aspirin use in adults age 70 years or older.

Colorectal Screening

Cheryl A. Glass

Refer to section Colorectal Cancer Screening of Chapter 14 and further review of other GI conditions:

A.The American Cancer Society (ACS) released their 2018 updated guidelines for colorectal cancer (CRC) screening for adults with average risk. New data indicates an increasing incidence of CRC among individuals younger than age 50 years. The incidence has increased by 51% since 1994:

1.Regular CRC screening with either a high-sensitivity stool-based test or a structural (visual) examination should begin at age 45 years among adults with average risk for CRC.

2.Adults aged 50 years and older should be screened regularly for CRC.

3.Among adults with average CRC risk who are in good health and have a life expectancy of more than 10 years, CRC should be continued through age 75 years.

4.CRC screening decisions should be individualized for patients age 76 through 85 years according to patient preferences, life expectancy, health status, and prior history of screening.

5.Continuing CRC screening is discouraged for individuals older than 85 years.

B.The U.S. Preventive Services Task Force (USPSTF) recommendations for screening for CRC by age ranges are:

1.Adults age 50 to 75 years:

a.The USPSTF recommends screening for CRC starting at age 50 years and continuing until age 75 years.

b.The risks and benefits of different screening methods vary.

2.Adults age 76 to 85 years:

a.The decision to screen for CRC in adults age 76 to 85 years should be an individual one, taking into account the patient’s overall health and prior screening history.

b.Adults in this age group who have never been screened for CRC are more likely to benefit.

c.Screening would be most appropriate among adults who are healthy enough to undergo treatment if CRC is detected and who do not have comorbid conditions that would significantly limit their life expectancy.

C.CRC prevention plays an important role in the overall health benefit of aspirin, but this benefit is not apparent until 10 years after aspirin therapy is started. Patients need to take aspirin for at least 5 to 10 years to realize this potential benefit, and persons with shorter life expectancy are less likely to benefit. Thus, aspirin use is more likely to have an effect when it is started between the ages of 50 and 59 years. See Table 2.2 for the USPSTF recommendation for aspirin use to prevent cardiovascular disease (CVD) and CRC.

Dental Care

Cheryl A. Glass

Research has linked infections from poor oral care from untreated cavities and gum disease to preterm birth, heart disease, diabetes, and respiratory diseases. Primary care providers are on the front line for performing oral examinations. Alcohol, drug use, smoking cigarettes, using pipes, and smokeless tobacco have been identified as among the major causes of poor oral health and partly responsible for the increase in risk of oral cancer.

Medicare does not cover routine dental care or dental procedures such as cleanings, fillings, tooth extractions, dentures, or other dental devices. Medicare Part A (hospital insurance) can pay for emergency or complicated dental procedures, even though dental care is not covered. Medicaid coverage for dental care varies by state. The Affordable Care Act (ACA) expansion of medical insurance coverage for dental services was required for children.

Primary care providers should provide education on good oral hygiene, including brushing, flossing, seeing a dentist at least yearly, and eating a healthy diet. The U.S. Preventive Services Task Force (USPSTF) has, however, found inadequate evidence that oral screening examinations accurately detect oral cancer or that treatment of screen-detected oral cancer improves morbidity or mortality.

Many dental schools provide care at reduced costs based on an individual’s income. The U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) has health centers in both cities and rural areas that provide care based on income. HRSA maintains a website to find the nearest HRSA-funded health centers at findahealthcenter.hrsa.gov/tool.

Depression Screening

Cheryl A. Glass

A.Screen for depression, regardless of risk factors, in the general adult population, age 18 years and older, including pregnant and postpartum women. Among older adults, risk factors for depression include disability and poor health status related to medical illness, complicated grief, chronic sleep disturbance, loneliness, and a history of depression. However, the presence or absence of risk factors alone cannot distinguish patients with depression from those without depression.

B.Screening is recommended by the U.S. Preventive Services Task Force (USPSTF) when staff-assisted depression care supports are in place to ensure accurate diagnosis, appropriate treatment, and appropriate follow-up.

C.There is little evidence regarding the optimal timing for screening. The optimum interval for screening for depression is also unknown. Screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events are used to determine if additional screening of high-risk patients is warranted.

TABLE 2.2 USPSTF Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication for Adults

Note: This recommendation applies to adults who are at increased CVD risk and at average risk for CRC. Persons who are at increased CVD risk and are known to be at increased risk for CRC (e.g., persons with a family or personal history of CRC or familial adenomatous polyposis) should consult their healthcare provider.

CRC, colorectal cancer; CVD, cardiovascular disease; USPSTF, U.S. Preventive Services Task Force.

D.There are multiple depression screening tools:

1.The Patient Health Questionnaire (PHQ-9) is the most common screening tool used to identify depression. The tool is located at img.medscape.com/pi/emed/ckb/psychiatry/79926-1889862-1859039-2128912.pdf.

2.The Hamilton Rating Scale for Depression (HAM-D) should be administered by a healthcare professional. The tool is located at img.medscape.com/pi/emed/ckb/psychiatry/79926-1889862-1859039-2124408.pdf.

3.The Cornell Scale for Depression in Dementia (CSDD) is located at www.scalesandmeasures.net/files/files/The%20Cornell%20Scale%20for%20Depression%20in%20Dementia.pdf.

4.The Geriatric Depression Scale (GDS) is located at img.medscape.com/pi/emed/ckb/psychiatry/285911-1335297-1859039-1859094.pdf. The GDS (short form) is located at img.medscape.com/pi/emed/ckb/psychiatry/285911-1335297-1859039-1859095.pdf.

5.The Edinburgh Postnatal Depression Screening (EPDS) is located at www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf.

E.All positive screening results should lead to additional assessment that considers the severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.

F.Medicare Part B covers an annual depression screening for Medicare beneficiaries in primary care settings when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up, thereby facilitating and coordinating referrals to mental health treatment. Medicare does not identify a specific depression screening tool.

G.The March 2016 Institute for Clinical System Improvement (ISCI) Adult Depression in Primary Care Guideline provides practitioners with current information related to screening for depression, including an algorithm for adult depression in the primary care setting, and the criteria for a major depressive episode from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association, 2013).

Diabetes Screening

Cheryl A. Glass

A.The incidence of type 2 diabetes mellitus (DM) is one of the major health problems facing the United States today and will continue to be an issue as the population ages and becomes more obese. The tests to be used for the diagnosis of diabetes are also utilized for screening for DM: the fasting plasma glucose, the 2-hour plasma glucose after a 75 g glucose tolerance test, and the hemoglobin A1C tests (see section Diabetes Mellitus of Chapter 24).

B.The U.S. Preventive Services Task Force (USPSTF) recommends screening in a primary care setting for abnormal blood glucose as part of cardiovascular risk assessment in adults age 40 to 70 years who are overweight or obese and do not have obvious symptoms of diabetes. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. Their recommendation further states that persons who have a family history of diabetes or a history of gestational diabetes or polycystic ovarian syndrome (POS) or are members of certain racial/ethnic groups (i.e., African Americans, American Indians or Alaskan Natives, Asian Americans, Hispanics or Latinos, or Native Hawaiians or Pacific Islanders) may be at increased risk for diabetes at a younger age or at a lower body mass index (BMI). Clinicians should consider screening earlier in persons with one or more of these characteristics.

C.The American Diabetes Association (ADA) screening recommendations are the following:

1.Screening for prediabetes and type 2 DM with an informal assessment of risk factors or validated tools should be considered in asymptomatic adults

2.Patient screening should begin at age 45 years for all people. Consider testing for prediabetes in asymptomatic adults of any age with a BMI of ≥25 kg/m² or 23 kg/m² (in Asian Americans) who have one or more additional risk factors for diabetes:

a.A1C ≥5.7, impaired glucose tolerance (IGT), or impaired fasting glucose (IFG) on previous testing.

b.First-degree relative with diabetes.

c.High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, and Pacific Islander).

d.Women who were diagnosed with gestational DM (GDM).

e.History of cardiovascular disease (CVD).

f.Hypertension (>140/90 mmHg) or receiving therapy for hypertension.

g.High-density lipoprotein (HDL) less than 35 mg/dL and/or a triglyceride level greater than 250 mg/dL.

h.Women with POS.

i.Physical inactivity.

j.Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans).

D.If the test results are normal, the ADA retesting for prediabetes and for type 2 diabetes at least at 3-year intervals is reasonable.

Hepatitis C Screening

Cheryl A. Glass

A.The U.S. Preventive Services Task Force (USPSTF) recommends offering a one-time screening for hepatitis C virus (HCV) infections to asymptomatic adults born between 1945 and 1965 without known liver disease or functional abnormalities.

B.The USPSTF also recommends screening for HCV infection in persons at high risk for infection:

1.The most important risk factor for HCV infection is past or current injection drug use. Intranasal drug use is also an additional risk factor.

2.Receipt of a blood transfusion before 1992.

3.Long-term hemodialysis and hemophilia.

4.Percutaneous exposures including unregulated tattoo.

5.High-risk sexual behaviors (multiple sex partners, unprotected sex, sex with an HCV-infected person or injection drug user, and men having sex with men [MSM]).

6.Birth to an HCV-infected mother.

7.Incarceration.

C.For those with reactive test results, the anti-HCV test should be followed with an additional, supplemental, or confirmatory test for the presence of the virus (see section Hepatitis C of Chapter 14).

HIV Screening

Cheryl A. Glass

A.HIV testing is a covered benefit from the Centers for Medicare and Medicaid Services (CMS) as a voluntary test every 12 months for people at increased risk and anyone asking for HIV testing. CMS also covers testing for HIV in pregnancy up to three times. In 2013, the U.S. Preventive Services Task Force (USPSTF) issued a final recommendation statement on HIV screening. This USPSTF is currently in the process of being updated. The current recommendation is that screening for HIV infection could begin at age 15 to 65 years. Teens younger than age 15 and adults older than 65 also should be screened if they are at risk for HIV infection (see section HIV of Chapter 20). USPSTF also recommends that all pregnant women, including women in labor who do not know their HIV status, be screened for HIV infection. High-risk factors for HIV are risky sexual practices (MSM, sexual partners with HIV, bisexual, exchanging sex for drugs or money) and infected IV drug users. For persons over age 65, new sexual partners are an increased risk.

B.Testing intervals are not defined by CMS or by the USPSTF.

Immunizations

Cheryl A. Glass

The Centers for Disease Control and Prevention (CDC) recommendations for immunizations are presented in Table 2.3.

Immunizations for travel outside of the United States are recommended based on the patient’s health status and vaccine history, as well as the area(s) of travel. The presence of the risk of becoming ill from poor sanitary conditions, food and water sources, and endemic diseases is considered in the CDC’s recommendations for travel immunizations. The CDC has an interactive tool for immunization recommendations for travel located at wwwnc.cdc.gov/travel/destinations/list.

Mammography

Cheryl A. Glass

Screening mammography guidelines:

A.The 2016 U.S. Preventive Services Task Force (USPSTF) screening mammography recommendations apply to asymptomatic women age 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as a BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age.

1.The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer.

2.In addition to false-positive results and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during their lifetime (known as overdiagnosis). Beginning mammography screening at a younger age and screening more frequently may increase the risk for overdiagnosis and subsequent overtreatment.

3.Women age 40 to 49 years: The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial (every other year) screening between the ages of 40 and 49 years. Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than averagerisk women from beginning screening in their 40s.

4.Women age 50 to 74 years: Biennial screening mammography.

5.Women age 75 years or older: The current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women age 75 years or older.

B.The 2017 American Congress of Obstetricians and Gynecologists (ACOG) recommendations for screening mammography include the following:

1.Ages 40 to 49: Offer screening mammography in the context of a shared, informed decision-making approach that recognizes the uncertainty of additional benefits and harms of clinical breast examination beyond screening mammography.

2.Ages 40 to 49: Initiate after counseling, if patient desires.

3.Ages 50 to 74: Recommend screening by no later than age 50, annual or biennial.

4.Continue until 75 years. Beyond age 75, the decision to discontinue should be based on a shared decision-making process that includes a discussion of the woman’s health status and longevity.

C.The 2015 American Cancer Society (ACS) mammography guideline recommendations are for women at average risk for breast cancer. Women at high risk, because of family history, a breast condition, or other reasons, need to begin screening earlier and more often.

1.Women should have the opportunity to begin annual screening between the ages of 40 and 44 years.

2.Women with an average risk of breast cancer should undergo regular screening mammograms at age 45.

3.Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually.

4.Women should continue screening mammograms as long as their overall health is good and they have a life expectancy of 10 years or longer.

Pap Smear/Pelvic Examination

Cheryl A. Glass

Human papillomavirus (HPV) increases the risk for cancer, including cervical, vulvar, vaginal, penile, and anal cancer as well as cancer of the oropharynx. Since cervical cancer is believed to be caused by sexually transmissible HPV infections, women who have not had sexual exposures are likely at low risk. Women older than 21 years who have not engaged in sexual intercourse may not need a Pap test depending on circumstances. The decision should be made at the discretion of the woman and her physician. Women who have had sex with women are still at risk of cervical cancer.

Prostate Cancer Screening

Cheryl A. Glass

A.Prostate cancer is one of the most common cancers in men. It is a slow-growing cancer with a lifetime risk of 11%, and the lifetime risk of dying of prostate cancer is 2.5%. The median risk of death from prostate cancer is 80 years. The risk factors for prostate cancer include:

1.Age: Men older than age 50.

2.Race/ethnicity: African American (4.2%), Hispanic (2.9%), Caucasian (2.3%), and Asian and Pacific Islander men (2.1%).

3.Men who have a family history of prostate cancer.

B.Smoking is associated with a high risk of prostate cancer mortality. The U.S. Preventive Services Task Force (USPSTF) 2018 recommendations for prostate-specific antigen (PSA) screening states:

1.The use of digital rectal examination as a screening modality is not recommended.

2.Men age 55 to 69 years:

a.The decision to undergo periodic PSA-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preference in the decision.

b.In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid conditions, patient values, and other health needs.

c.Clinicians should not screen men who do not express a preference for screening.

3.Men 70 years and older: USPSTF recommends against PSA-based screening for prostate cancer, noting adequate evidence from randomized clinical trials (RCT) is consistent with no benefit of PSA-based screening for prostate cancer because there is a lack of evidence on the benefits.

4.Harms of screening include frequent false-positive results with subsequent overdiagnoses, which can result in overtreatment including invasive procedures, chemotherapy, and radiation.

Screening for prostate cancer with the PSA has been controversial because of the potential of overdiagnosis and overtreatment. The PSA may be elevated with prostate problems other than cancer. Further testing for suspected prostate cancer includes a digital rectal examination (not a current recommendation), transrectal ultrasound, and/or a needle biopsy.

Active surveillance with continued observation and physical examinations is a more common treatment choice over the past several years among men with low-risk prostate cancer and may reduce the chance of overtreatment. Active surveillance includes periodic PSA tests, physical examination, and repeated prostate biopsy, an often repeated rectal examination. Treatment includes prostatectomy surgery, radiation, or androgen deprivation therapies. Side effects of these procedures include urinary incontinence, erectile dysfunction, and bowel dysfunction. The use of androgen deprivation therapy for localized prostate cancer is associated with erectile dysfunction, gynecomastia, and hot flashes.

Sexually Transmitted Infections Screening

Cheryl A. Glass

Taking a thorough sexual history is the basis of identifying high-risk sexual behavior, screening, counseling, and treatment for sexually transmitted infections (STIs). Older men and women should continue to be screened throughout their lifetime for STIs; there is no cutoff on age for the transmission of STIs. All persons who seek evaluation and treatment for STIs should be screened for HIV. Screening should be routine, regardless of whether the patient reports any specific behavioral risk for HIV. The Centers for Disease Control and Prevention (CDC) recommends that persons 13 to 64 years of age be screened for HIV in all healthcare settings. Persons should be notified that testing will be performed, but retain the option to decline or defer testing. Guidelines and recommendations for HIV/AIDS for clinicians are available at the CDC website located at www.cdc.gov/hiv/guidelines/index.html. For more discussion on sexual health and treatment guidelines for STIs and HIV see section Sexual Health Issues in the Aging Population of Chapter 17; full CDC STI guidelines in Chapter 18; and section HIV of Chapter 20.

Vision Screens

Cheryl A. Glass

Age-related changes affect the sense of sight and require screening for refractory errors, macular degeneration, glaucoma, and cataracts (see Chapter 8).

Multiple medical and systemic conditions including genetic, cardiovascular, endocrine, GI, nutritional, and metabolic disorders increase the need for a comprehensive dilated eye examination. The American Optometric Association recommends an examination every 2 years for risk-free adults between 18 and 60 years. For those at risk between 18 and 60 years of age, eye examinations are recommended every 1 to 2 years. For adults who are 61 years of age and older who are risk free, an annual eye examination is recommended. A comprehensive eye examination for at-risk adults should occur annually or as recommended. The American Academy of Ophthalmology recommends a baseline comprehensive exam at age 40. The Academy’s recommendation is for all adults with no signs or risk factors for eye disease. Based on the results of the initial screening, an ophthalmologist will prescribe the necessary intervals for follow-up exams.

Pretravel Health Screenings

Cheryl A. Glass

A.Pretravel consultation offers a dedicated time to prepare travelers for the health concerns that might arise during their trips. The objective is to perform an individual risk assessment, educate the traveler regarding anticipated health risks and methods for prevention, and provide immunizations for vaccine-preventable diseases and medications for prophylaxis, self-treatment, or both. Travel medicine specialists have in-depth knowledge of immunizations, risks associated with specific destinations, and the implications of traveling with underlying conditions. Therefore, a comprehensive consultation with a travel medicine expert is indicated for any traveler with a complicated health history, special risks (such as traveling at high altitudes or working in refugee camps), or exotic or complicated itineraries.

B.Effective pretravel consultations require attention to the health background of the traveler and incorporate the itinerary, trip duration, travel purpose, and activities, all of which determine health risks.

1.Risk assessment:

a.Past medical history including underlying conditions, allergies (especially any pertaining to vaccines, egg, or latex), and medications.

b.Special conditions including pregnancy, breastfeeding, disabilities, immunocompromising conditions or medications, seizure disorder, recent myocardial infarction (MI), surgery, and history of Guillain-Barré syndrome.

c.Immunization history: Routine and travel vaccines.

d.Prior travel experience including malaria chemoprophylaxis, experience with altitude, and illness related to prior travel.

2.Trip details:

a.Itinerary: Countries and specific regions, including the travel order of countries as well as rural or urban travel.

b.Timing: Trip duration, season of travel, time to depart.

c.Reason for travel: Tourism, business, visiting friends/relatives, missionary/aid work, adoption, or seeking healthcare (medical tourism).

d.Travel style: Independent travel or package tour, traveler risk tolerance, general hygiene standards at the destination, modes of transport, accommodations, and propensity for adventurous eating.

e.Special activities: Disaster relief, medical care (providing or receiving), high altitude, diving, cruise ship, rafting or other water exposure, cycling, extreme sports, spelunking, and anticipated interactions with animals.

C.Assess individual risks: Many elements merit consideration in assessing a traveler’s health risks (Table 2.1). Certain travelers may confront special risks. Recent hospitalization for serious problems may lead the advisor to recommend delaying travel. Air travel is contraindicated for certain conditions, such as less than 3 weeks after an uncomplicated MI and less than 10 days after thoracic or abdominal surgery. The travel health provider and traveler should consult with the relevant healthcare providers most familiar with the underlying illnesses.

D.Manage risk:

1.Immunizations are a crucial component of pretravel consultations, and the risk assessment forms the basis of recommendations for travel vaccines.

2.For travelers going to malaria-endemic countries, it is imperative to discuss malaria transmission, ways to reduce risk, and recommendation for chemoprophylaxis.

3.Travelers with underlying health conditions require attention to their health issues as they relate to the destination and activities. Travelers should be counseled on how they can find reputable medical facilities at their destination, such as using the International Society of Travel Medicine (ISTM) website (www.istm.org) or the American Society of Tropical Medicine and Hygiene website (www.astmh.org) to find suitable clinics. Any allergies or serious medical conditions should be identified on a bracelet or a card to expedite medical care in emergency situations.

4.The pretravel consultation also provides another setting to remind travelers of basic health practices during travel, including frequent handwashing, wearing seatbelts, and using car seats for infants and children. General issues such as preventing injury and sunburn also deserve mention. Written information is essential to supplement oral advice and enable travelers to review the instructions from their clinic visits; educational material is available on the Centers for Disease Control and Prevention (CDC) Travelers Health webpage (www.cdc.gov/travel). Advice on self-treatable conditions may minimize the need for travelers to seek medical care while abroad.

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Healthy Living for Adult-Geriatric Patients

Health Maintenance During the Life Span

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