Chapter 15: Health Maintenance for Adults

On average, each day longer you live, the longer you are likely to live, yet the closer to dying you become. The goal of health maintenance (HM) is to help people live longer and healthier lives.

In this chapter, the findings and positions of the United States Preventative Service Task Force (USPSTF) are emphasized because it generates the most comprehensive and evidence-based recommendations of any organization. Hence, knowing the USPSTF grading system for its recommendations is important (Table 15-1). The USPSTF is sponsored by the Agency for Healthcare Research and Quality (AHRQ) and is the leading independent panel of private-sector experts in prevention and primary care.

This chapter describes prevention then presents HM by the age groups 18-39, 40-49, 50-59, 60-74, and ≥75 years of age. USPSTF Grade A and B recommendations are emphasized with highlights to some areas of special interest or controversy, including sections on immunizations and aspirin.

Health maintenance involves three types of prevention: primary, secondary, and tertiary (Figure 15-1).

A. Primary Prevention

Targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (eg, childhood vaccination programs, water fluoridation, smoking prevention programs, clean water, and sanitation). The disease does not exist. The goal is to prevent development of disease.

B. Secondary Prevention

Targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (eg, routine Papanicolaou smears; screening for hypertension, diabetes, or hyperlipidemia). The disease does exist, but the person is unaware (asymptomatic). The goal is to identify and treat people with disease.

C. Tertiary Prevention

Treatment targets individuals with a known disease, with the goal of limiting or preventing future complications (eg, rigorous treatment of diabetes mellitus, post–myocardial infarction treatment with β-blockers and aspirin). The disease exists and there are symptoms. The goal is to prevent complications.

Secondary and tertiary prevention require some type of screening. This raises important issues: (1) who should be screened, (2) for which disease(s), and (3) with what test(s)(Table 15-2).

1. The disease

The disease must have a period of being detectable before the symptoms start so that it can be found and treated; for instance, colon cancer has no early symptoms but can be detected with screening. The disease cannot appear too quickly, such as a cold and certain lung cancers. The disease must be common in the target population; for instance, stomach cancer is not screened for in the United States (uncommon), but it is screened for in Japan, where is it is more common.

2. The test

Ideally the screening test will identify all people with disease and only people with disease will test positive. In reality, screening tests are acceptable if they do the job well enough—sensitive enough to have few false negatives and specific enough to have few false positives. Screening tests should also be cost-efficient, easy, reliable, and as painless as possible.

3. Treatment

When screening for disease, treatment must be available, be acceptable, and have benefits that outweigh the risk. Mortality is the most often used endpoint. If a group of people who are screened and then treated live longer or better than a group of people who are not screened, then the screening test may be good for that population. If the two groups of people die at the same rate, there is usually no point in screening for the disease.

A. Health Maintenance: Across the Ages What Not to Do

Conditions for which the USPSTF recommends against routine screening in asymptomatic adults:

• Aspirin to prevent myocardial infarction in men aged <45 years

• Asymptomatic bacteriuria in men and nonpregnant women

• Bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery

• BRCA-related cancers in women not at increased risk

• Cancers: cervix (if hysterectomy), ovary, pancreas, prostate, testicular

• Carotid artery stenosis

• Chronic obstructive pulmonary disease

• Electrocardiography (ECG)

• Genital herpes

• Gonorrhea in low-risk men and women

• Heart disease in low-risk patients using ECG, electron-beam computed tomography (EBCT)

• Hemochromatosis

• Hepatitis B

• Routine aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for primary prevention of colorectal cancer for average risk

• Scoliosis

• Stress echocardiogram

• Syphilis

Vitamin supplements with β-carotene to prevent cancer and cardiovascular disease (CVD)

B. Health Maintenance: Across the Ages—Insufficient Evidence

Conditions for which the USPSTF found insufficient evidence to promote routine screening in asymptomatic adults at low risk:

• Abuse of elderly and vulnerable adults

• Cancers: bladder, oral, skin

• Chlamydia in men

• Clinical breast examination beyond screening mammography, women aged ≥40 years

• Dementia

• Diabetes mellitus if blood pressure (BP) <135/80 mmHg

• Drug abuse

• Family violence

• Gestational diabetes mellitus

• Glaucoma

• Lung cancer

• Peripheral artery disease with the ankle-brachial index

• Suicide risk

• Thyroid disease

• Vitamin supplementation with A, C, E, multivitamins to prevent cancer and heart disease

• Vitamin D and calcium supplementation to prevent fractures: men, premenopausal women

C. Health Maintenance: Across the Ages—Aspirin

The role of aspirin in health maintenance and promotion varies according to whether it is used for primary or secondary/tertiary prevention. For the latter, it is generally beneficial (Table 15-3). For primary prevention it is not that simple (Tables 15-4, 15-5, and 15-6). The USPSTF recommends against the routine use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in persons at average risk for colorectal cancer (grade D recommendation).

D. Health Maintenance: Ages 18–39

Table 15-7 summarizes USPSTF grade A and grade B screening and counseling recommendations for average-risk 18–39-year-olds. Below the screening tests in focus are as follows: hypertension, cervical cancer, Chlamydia, lipid disorders, depression, tobacco, and specific screening for those at increased risk.

1. Hypertension

Hypertension is the most common condition seen in family medicine. It contributes to many adverse health outcomes, including premature deaths, heart attacks, renal insufficiency, and stroke. Blood pressure measurement identifies individuals at increased risk for cardiovascular disease. Treatment of hypertension decreases the incidence of cardiovascular disease events.

Hypertension is defined as elevated blood pressure, either systolic blood pressure (SBP) or diastolic blood pressure (DBP), on at least two separate occasions separated by one to several weeks. In persons

• 18–60 years of age—elevation is either a SBP of ≥140 mmHg or a DBP of ≥90 mmHg.

• ≥60 years of age—elevation is either a SBP of ≥150 mmHg or a DBP of ≥90 mmHg.

• ≥18 years of age with chronic kidney disease—defined as an estimated or measured glomerular filtration rate of <60 mL/min per 1.73 m² in individuals aged <70 years–elevation is either a SBP of ≥140 mmHg or a DBP of ≥90 mmHg.

• Of any age with albuminuria (>30 mg of albumin/g of creatinine)—elevation is either a SBP of ≥140 mmHg or a DBP of ≥90 mmHg.

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC8) recommends screening every 2 years in persons with blood pressure of <120/80 mmHg and every year with systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–90 mmHg. The American Heart Association (AHA) has issued similar recommendations beginning at age 20.

Hypertension should be treated. Treatment is addressed in Chapter 35.

2. Cervical cancer

Cervical cancer screening is discussed in detail in Chapter 27.

3. Chlamydia screening

The USPSTF recommends screening for Chlamydia infection in all sexually active women aged ≤24 years, or women aged ≥25 years at increased risk. The optimal screening interval for nonpregnant women is unknown. The CDC recommends at least annual screening for women at increased risk. Chlamydia trachomatis infection is the most common sexually transmitted bacterial infection in the United States. In women, genital infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality. The benefits of screening and subsequent treatment in high-risk pregnant and nonpregnant individuals are substantial.

The USPSTF identified no evidence of the benefits of screening women who are not at increased risk for Chlamydia infection. In this low-risk population it is moderately certain that the benefits outweigh the risks of screening to only a small degree. Nucleic acid amplification tests (NAATs) for Chlamydia have high specificity and sensitivity as screening tests and may be used with either urine or vaginal swabs.

Screening of pregnant women for Chlamydia infection is recommended for all women at the first prenatal visit. For those who remain at increased risk or acquire a new risk factor, such as a new sexual partner, screening should be repeated during the third trimester.

4. Lipid disorders

Men aged >35 years should be screened for lipid disorders. This age may be reduced to 20 if there is an increased risk for coronary heart disease. Screening for women does not need to start until age 45.

The optimal interval for screening is uncertain. Reasonable options include every 5 years, with shorter intervals for those with risk factors (eg, diabetes mellitus) or lipid levels close to those warranting therapy.

High levels of total cholesterol (TC) and low-density lipoprotein-cholesterol (LDL-C) and low levels of high- density lipoprotein–cholesterol (HDL-C) are independent risk factors for coronary heart disease. The risk is highest in those with a combination of risk factors. Therefore, a careful review of the complete risk factor profile is necessary to assess the benefit of screening and subsequent lowering of high cholesterol levels with medications. (Please see Chapter 37 for a full discussion of lipid disorders.)

5. Depression screening

Depression is common and a leading cause of disability in both adolescents and adults. Screening for depression improves the accurate identification of depressed patients in primary care settings. The USPSTF concluded that the net benefit of screening adults for depression is higher (moderate) when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up. In the absence of such care supports, the net benefit may be small. Numerous formal screening tools are available, but there is insufficient evidence to recommend one tool over another. All positive screens should trigger a full diagnostic interview.

6. Tobacco use counseling

Cessation of tobacco use may be the single most important lifestyle intervention for the maintenance and improvement of health. All adults should be assessed for tobacco use and tobacco cessation interventions provided for those who use tobacco products. Tobacco use, cigarette smoking in particular, is the leading cause of preventable death in the United States, resulting in >400,000 deaths annually from cardiovascular disease, respiratory disease, and cancer. Smoking during pregnancy results in the deaths of approximately 1000 infants annually and is associated with an increased risk for premature birth and intrauterine growth retardation. Environmental tobacco smoke may contribute to death in ≤38,000 people annually.

Cessation of tobacco use is associated with a corresponding reduction in the risk of heart disease, stroke, and lung disease. Tobacco cessation at any point during pregnancy yields substantial health benefits for the expectant mother and fetus.

Smoking cessation interventions, including brief (<10 minutes) behavioral counseling sessions and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit and remain abstinent for 1 year. Even minimal counseling interventions (<3 minutes) are associated with improved smoking cessation rates. One of several screening strategies aimed at engaging patients in smoking cessation discussions is the “5A” behavioral counseling framework:

1. Ask about tobacco use.

2. Advise to quit through clear personalized messages.

3. Assess willingness to quit.

4. Assist to quit.

5. Arrange follow-up and support.

7. Screening and counseling specifically for persons aged 18–39 years at increased risk

• HIV—screen once for all persons aged 15–65 years, more for those at increased risk (A).

• Syphilis—screen for men and women at increased risk (A).

• BRCA mutation testing for breast and ovarian cancer (B).

• Gonorrhea—screen women who are pregnant or at increased risk (B).

• Healthy diet—screen adults with hyperlipidemia and other risk factors for coronary heart disease (CHD) (B).

• Intimate-partner violence—screen women of childbearing age (B).

• Sexually transmitted infections—provide behavioral counseling for sexually active adolescents and adults at increased risk (B).

• Skin cancer—provide behavioral counseling for children, adolescents, and young adults aged 18–24 years (B).

• Type 2 diabetes mellitus—screen men and women with sustained blood pressure of ≥135/80 mmHg (B).

• Lipid disorders in adults—screen women aged 20–44 and men aged 20-34 years at increased risk for CHD (B).

E. Health Maintenance: Ages 40–49 with Emphasis on Breast Cancer and Lipid Screening

Tables 15-8, 15-9, and 15-10 summarize USPSTF recommendations for average-risk 40–49-year-olds.

1. Breast cancer

Please see Tables 15-9 and 15-10 and Chapter 27 for discussion of screening for breast cancer.

2. Lipid screening

All women aged ≥45 years should be screened for lipid disorders. Women aged 20–44 years should be screened if they are at increased risk for coronary heart disease (CHD). Increased risk, for this recommendation, is defined by the presence of any of the following risk factors: diabetes, previous personal history of CHD or noncoronary atherosclerosis (eg, abdominal aorta aneurysm, peripheral artery disease, carotid artery stenosis), a family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives, tobacco use, hypertension, obesity (BMI >30). (Further discussion of dyslipidemia is found in section on health maintenance for ages 18–39 years (above) and in Chapter XX.)

F. Health Maintenance: Ages 50–59

Table 15-11 summarizes USPSTF recommendations for average-risk 50–59-year-olds, with major changes in recommendations for prostate and lung cancer screening.

1. Colorectal cancer screening

This should occur from age 50 to 75 years using a variety of tests, as follows:

• Sensitivity—Hemoccult II < fecal immunochemical tests < Hemoccult SENSA ≈ flexible sigmoidoscopy < colonoscopy

• Specificity—Hemoccult SENSA < fecal immunochemical tests ≈ Hemoccult II < flexible sigmoidoscopy = colonoscopy

Screening with fecal occult blood testing, sigmoidoscopy, or colonoscopy reduces mortality, assuming 100% adherence to any of these regimens: (1) annual high-sensitivity fecal occult blood testing, (2) sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years, or (3) screening colonoscopy at intervals of 10 years. Evidence is insufficient regarding screening with fecal DNA or CT colonography.

For a more complete discussion of colorectal cancer screening, see Chapter XX.

2. Hypertension

Screen every 2 years if blood pressure is <120/80 mmHg and every year with systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–90 mmHg.

3. Aspirin

Benefits must outweigh risks. See earlier discussion of acetylsalicylic acid (ASA) and Tables 15-3, 15-4, 15-5, and 15-6. Aspirin should not be initiated to prevent stroke in women aged <55 years of age. Aspirin should not be used to prevent colorectal cancer in persons at average risk for colorectal cancer.

4. Prostate cancer screening (USPSTF recommendation D)

As discussed earlier, an effective screening test should detect disease early, and early treatment should improve morbidity and mortality. There is no conclusive evidence that treatment of prostate cancers detected by screening improves outcomes. Recognition of the fact that most men with prostate cancer do not die and the limitations of currently available prostate screening tests has led to fluidity regarding the best prostate screening practices. As new data become available, the guidelines from major organizations seem to be increasingly similar with some nuances.

The USPSTF recommends against prostate cancer screening (recommendation D), based on their conclusion of the current evidence that there is very small potential benefit and significant potential risk from screening. The American Academy of Family Physicians (AAFP) supports the USPSTF guidelines.

The American Cancer Society (ACS) recommends that men make an informed decision with their physicians as to whether they should be tested for prostate cancer. Starting at age 50 years, men should discuss the pros and cons of testing with a physician. If they are African American or have a father or brother who had prostate cancer before age 65, men should discuss testing with a physician starting at age 45. If men decide to be tested, they should opt for the prostate-specific antigen (PSA) blood test with or without a rectal exam. How often they are tested will depend on their PSA level.

The American Urologic Association (AUA) guidelines are as follows:

• PSA screening in men under age 40 years is not recommended.

• Routine screening in men aged 40–54 years at average risk is not recommended.

• For men aged 55–69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1000 men screened over a decade against the known potential risks associated with screening and treatment. For this reason, shared decision making is recommended for men aged 55–69 years who are considering PSA screening, and proceeding according to patients’ values and preferences.

• To reduce the harms of screening, a routine screening interval of ≥2 years may be preferred over annual screening in those men who have participated in shared decision making and decided on screening. As compared to annual screening, it is expected that 2-year screening intervals will preserve most of the benefits and reduce the risk of overdiagnosis and false positives.

• Routine PSA screening is not recommended in men over age 70 or any man with a <10–15-year life expectancy.

The reasons for these changes away from the prior recommendations to screen are based on new, large, long-running studies. Also, epidemiologic data factor in as well. Prostate cancer is the most common nondermatologic cancer in US males. If they live to be 90 years old, one out of six US males will be diagnosed with prostate cancer. Risk factors for development of prostate cancer include advanced age, family history, and race. Nearly 70% of prostate cancer diagnoses occur in men aged ≥65 years. The risk of developing prostate cancer is nearly 2.5 times greater in men with a family history of prostate cancer in a first-degree relative. Rates of prostate cancer occurrence are lower in Asian and Hispanic males than in non-Hispanic Caucasian males. African-American men are at twice the risk of white men. While US men have an approximately 16% lifetime risk of being diagnosed with prostate cancer, they have only ~3% risk of dying from it.

Digital rectal examination (DRE) and prostate-specific antigen (PSA) testing are the most commonly used prostate cancer screening tools. Physician-performed DRE is limited in that it allows only a portion of the prostate gland to be palpated and has poor interrater reliability. Sensitivity of DRE is low (53–59%), and positive predictive value (PPV) is only 18–28%. The PPV of PSA for prostate cancer screening is similarly low, at ~30%. Proposed prostate cancer screening methods include using PSA cutoff of 4 ng/mL, measuring PSA velocity, and percent free PSA. No currently available data demonstrates a mortality benefit with any of these. Whether DRE adds value to PSA screening is debatable, if not doubtful. DRE should not be used as a standalone test to screen for prostate cancer.

Both DRE and PSA screening can lead to detection of clinically insignificant prostate cancers, exposing patients to undue psychological distress and potentially harmful procedures and treatments, such as biopsy and radical prostatectomy. Unfortunately, DRE and PSA screening can also miss aggressive prostate cancers.

5. Lung cancer screening

The USPSTF assigns a B recommendation to annual screening for lung cancer with low-dose computed tomography in adults aged 55–80 years who have a 30-pack/yr smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to undergo curative lung surgery. This has been a controversial recommendation because of concerns about radiation exposure (high false positive findings on initial screen leading to more CT scanning; the 25-year recommendation is based on studies of 3 years of screening), cost-benefit concerns, and the unsure role of screening in people who continue to smoke (eg, whether a negative screen will impede the desire to quit, whether a false-positive screen will result in increased quit rates). The AAFP has not endorsed this recommendation. Like all USPSTF recommendations, it will be reevaluated as new data emerge.

G. Health Maintenance: Ages 60–74

Table 15-12 summarizes USPSTF recommendations for average-risk 60–74-year-olds.

Screening tests in focus: Abdominal aortic aneurysm (AAA) and osteoporosis.

1. Screening for abdominal aortic aneurysm (AAA), men only:

• One-time screening for AAA by ultrasonography in men aged 65–75 who have ever smoked (B).

• No recommendation for or against screening for AAA in men aged 65–75 years who have never smoked (C).

• Against routine screening for AAA in women (D), due to false-positive rate and lower prevalence of AAA.

2. Screening for osteoporosis in postmenopausal women:

• All women aged ≥65 years should be screened routinely for osteoporosis (B).

• Women at increased risk¹ for osteoporotic fractures should begin screening at age 60 (B).

• No recommendation for or against routine osteoporosis screening in postmenopausal women aged <60 or in women aged 60–64 years who are not at increased risk for osteoporotic fractures (C).

Screening should occur every 3 years even if treatment is initiated.

Osteoporosis Risk Assessment Tools

• Foundation on Osteoporosis Research and Education (FORE) 10-year Risk Calculator at https://riskcalculator.fore.org/default.aspx

• FRAX^® WHO Fracture Risk Assessment Tool at http://www.shef.ac.uk/FRAX/tool.jsp?country=9

• The Osteoporosis Risk Assessment Instrument (ORAl) uses age, weight, and the use of estrogen as an aid to selecting postmenopausal patients for bone density testing (Cadarette, et al. 2000).

H. Health Maintenance: Age ≥75

Perhaps the most important aspect of health maintenance in people aged ≥75 years is lifestyle. HM recommendations for this age group are summarized in Table 15-13 and discussed below.

In patients aged ≥75 years, health maintenance decisions become more complex. The focus remains both primary and secondary prevention; however, there are relatively few studies evaluating the utility and impact of HM interventions in this population. Therefore, it becomes increasingly important to work with geriatric patients to make informed, individualized HM decisions. Among patients aged ≥75 years, there exist wide variations in the number and severity of comorbid conditions, functional status, life expectancy, and patients’ overall goals of care and preferences. Each of these factors must be considered when discussing HM interventions in older patients. Consideration of both benefits and risks of any HM intervention is also essential.

Guidelines regarding cancer screening in patients aged ≥75 years especially require individualized, patient-specific discussions and decisions. The United States Preventive Task Force (USPSTF) suggests that the benefits of colon cancer screening in adults aged 75–85 years do not outweigh the risks, and explicitly recommends against it in patients aged >85 years. The American College for Gastroenterology (ACG) recommends colon cancer screening beginning at age 50 and does not suggest when to discontinue screening.

For breast cancer screening, USPSTF recommends neither for nor against mammography in women aged ≥75 years. The American Geriatric Society (AGS) recommends screening mammography every 3 years after age 75 with no upper age limit for women with an estimated life expectancy of ≥4 years. The American Cancer Society (ACS) and USPSTF agree that older women with previously negative Pap results do not benefit from ongoing screening for cervical cancer after the age of 75.

Prostate cancer screening remains a controversial topic, with USPSTF advising against the use of prostate-specific antigen (PSA) for prostate cancer. A detailed discussion of prostate cancer and prostate cancer screening is included elsewhere in this chapter.

The American Geriatric Society recommends screening all older adults for a history of falls within the last year, and USPSTF recommends the use of exercise, physical therapy, and vitamin D supplementation in community-dwelling older adults at increased risk for falls. USPSTF recommends neither for nor against screening for vision impairment, hearing impairment or dementia in asymptomatic patients aged ≥75 years.

I. Health Maintenance: Adult Immunizations

Tables 15-14 and 15-15 summarize the vaccination recommendations for adults.