Chapter 2: Promoting Good Health
Donald M. Lloyd-Jones; Kathleen M. McKibbin
GOALS AND APPROACHES TO PREVENTION
HEALTH PROMOTION
PRIORITIZING PREVENTION STRATEGIES
PREVENTION AND HEALTH PROMOTION ACROSS THE LIFE COURSE
Periodic Health Evaluations
Healthy Behaviors and Lifestyles
Healthy Eating Patterns
Physical Activity
Sleep Hygiene
Weight Management
Tobacco Cessation
MENTAL HEALTH AND ADDICTION
Alcohol and Opioids
ACCIDENTS AND SUICIDE
APPROACH TO THE PATIENT
GOALS AND APPROACHES TO PREVENTION
Prevention of acute and chronic diseases before their onset has been recognized as one of the hallmarks of excellent medical practice for centuries, and is now used as a metric for highly functioning healthcare systems. The ultimate goal of preventive strategies is to avoid premature death. However, as longevity has increased dramatically worldwide over the last century (largely as a result of public health practices), increasing emphasis is placed on prevention for the purpose of preserving quality of life and extending the healthspan, not just the lifespan. Given that all patients will eventually die, the goal of prevention ultimately becomes compression of morbidity toward the end of the lifespan; that is, reduction of the amount of burden and time spent with disease prior to dying. As shown in Fig. 2-1, normative aging tends to involve a steady decline in the stock of health, with accelerating decline over time. Successful prevention offers the opportunity both to extend life and to extend healthy life, thus “squaring the curve” of health loss during aging.
FIGURE 2-1
Loss of health with aging. Representation of normative aging with loss of the full stock of health with which individuals are born (indicating gain of morbidity), contrasted with a squared curve with greater longevity and fuller stock of health (less morbidity) until shortly before death. The “squared curve” represents the likely ideal situation for most patients.
The image shows a graph depicting loss of health with aging contrasted with a squared curve with greater longevity and less morbidity by prevention.
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Prevention strategies have been characterized as tertiary, secondary, primary, and primordial. Tertiary prevention requires rapid action to prevent imminent death in the setting of acute illness, such as through percutaneous coronary intervention in the setting of ST-segment elevation myocardial infarction. Secondary prevention strategies focus on avoiding the recurrence of disease and death in an individual who is already affected. For example, tamoxifen is recommended for women with surgically treated early-stage, estrogen-receptor-positive breast cancer, because it reduces the risk of recurrent breast cancer (including in the contralateral breast) and death. Primary prevention attempts to reduce the risk of incident disease among individuals with a risk factor. Treatment of elevated blood pressure in individuals who have not yet experienced cardiovascular disease represents one example of primary prevention that has proven effective in reducing the incidence of stroke, heart failure, and coronary heart disease.
Primordial prevention is a more recent concept (first introduced in 1979) which focuses on prevention of the development of risk factors for disease, not just prevention of disease. Primordial prevention strategies emphasize upstream determinants of risk for chronic diseases, such as eating patterns, physical activity, and environmental and social determinants of health. It therefore encompasses medical treatment strategies for individuals as well as a strong reliance on public health and social policy. It is increasingly clear that primordial prevention represents the ultimate means for reducing the burden of chronic diseases of aging. Once risk factors develop, it is difficult to restore risk to the low level of someone who never developed the risk factor. The time spent with adverse levels of the risk factor often causes irreversible damage that precludes complete restoration of low risk. For example, individuals with hypertension who are treated back to optimal levels (<120 a="" abolish="" age="" all="" also="" and="" antihypertensive="" as="" atherosclerosis="" be="" below="" blood="" burden="" but="" cannot="" cardiovascular="" comorbid="" compared="" compression="" conversely="" damage="" described="" despite="" detail="" developing="" disease="" do="" efficacious="" elevated="" essentially="" events="" evidence="" factors="" fully="" function="" greater="" have="" having="" hypertension="" illnesses="" in="" index="" individuals="" into="" is="" left="" levels="" lifetime="" living="" longer="" lower="" maintain="" maintained="" major="" mass="" medications.="" middle="" mmhg="" morbidity="" more="" of="" optimal="" organ="" other="" p="" patients="" pressure="" prevention="" primordial="" renal="" result="" reversed="" risk="" spent="" still="" subsequently="" substantially="" such="" target="" that="" the="" their="" therapy="" they="" those="" through="" time="" treated="" twice="" untreated="" ventricular="" while="" who="" with="" without="" worse="">
Prevention strategies should be distinguished from disease screening strategies. Screening attempts to detect evidence of disease at its earliest stages, when treatment is likely to be more efficacious than for advanced disease (Chap. 4). Screening can be performed in service of prevention, especially if it aids in identifying pre-clinical markers associated with elevated disease risk.
HEALTH PROMOTION
In recent decades, medical practice has increasingly focused on public health approaches to promote health, and not just prevent disease. Prevention of disease is a worthy individual and societal goal in and of itself, but it does not necessarily guarantee health. Health is a broader construct encompassing more than just absence of disease. It includes biological, physiological, and psychological domains (among others) in a continuum, rather than occurring as a dichotomous trait. Health is therefore somewhat subjective, but attempts have been made to use more objective criteria to define health in order to raise awareness, prevent disease, and promote healthy longevity.
For example, in 2010 the American Heart Association (AHA) defined a new construct of “cardiovascular health” based on evidence of associations with longevity, disease avoidance, healthy longevity, and quality of life. The definition of cardiovascular health is based on seven health behaviors and health factors (eating pattern, physical activity, body mass, smoking status, and levels of blood pressure, blood cholesterol, and blood glucose) and includes a spectrum from poor to ideal. Individuals with optimal levels of all seven metrics simultaneously are considered to have ideal cardiovascular health. The state of cardiovascular health for an individual or a population can be assessed with simple scoring by counting the number of ideal metrics (out of 7) or applying 0 points for each poor metric, 1 point for each intermediate metric, and 2 points for each ideal metric, thus creating a composite cardiovascular health score ranging from 0 to 14 points. Higher cardiovascular health scores in younger and middle ages have been associated with greater longevity, lower incidence of cardiovascular disease, lower incidence of other chronic diseases of aging (including dementia, cancer, and more), compression of morbidity, greater quality of life, and lower healthcare costs, achieving both individual and societal goals for healthy aging, and further establishing the critical importance of primordial prevention and cardiovascular health promotion.
Focusing on health promotion, rather than just disease prevention, may also provide greater motivation for patients to pursue lifestyle changes or adhere to clinician recommendations. Extensive literature suggests that providing patients solely with information regarding disease risk, or risk reduction with treatment, is unlikely to motivate desired behavior change. Empowering patients with strategies to achieve positive health goals after discussing risks can provide more effective adherence and better long-term outcomes. In the case of smoking cessation, enumerating only the risks of smoking can lead to patient inertia and therapeutic nihilism, and has proven an ineffective approach, whereas strategies that incorporate positive health messaging, support and feedback, with appropriate use of evidence-based therapies, have proven far more effective.
PRIORITIZING PREVENTION STRATEGIES
In secondary prevention, the patient already has manifest clinical disease, and is therefore at high risk for progression. The approach should be to work with the patient to implement all evidence-based strategies that will help to prevent recurrence or progression. This will typically include drug therapy as well as therapeutic lifestyle changes to control ongoing risk factors which may have caused disease in the first place. Juggling priorities can be difficult, and barriers to implementation are many, including costs, time, patient health literacy, and patient and caregiver capacity to organize the regimen. Addressing these potential barriers with the patient can help to forge a therapeutic bond and may improve adherence; ignoring them will likely lead to therapeutic failure. Numerous studies demonstrate that, even in high-functioning health systems, only ~50% of patients are taking recommended, evidence-based secondary prevention medications, such as statins, by 1 year after a myocardial infarction.
In patients who are eligible for primary prevention strategies, it is important to frame the discussion around the overall evidence base as well as an individual patient’s likelihood of benefit from a given preventive intervention. A first step is to understand the patient’s estimated absolute risk for disease in the foreseeable future, or during their remaining lifespan. However, absolute risk estimation and presentation of those risks is generally insufficient to motivate behavior change. It is critical to assess the patient’s understanding and tolerance of the risk, their readiness to implement lifestyle changes or adhere to drug therapy, and their overall preferences regarding use of drug therapy to prevent an event (e.g., cancer, myocardial infarction, stroke). The clinician can help the patient by informing them of the risks for disease and potential for absolute benefits (and harms) from the available evidence-based choices. This may take more than one conversation, but given that diseases, such as cancer and cardiovascular disease, are the leading causes of premature death and disability, the time is well spent.
Partnering with the patient through motivational interviewing may assist in the process of selecting initial approaches to prevention. Selecting an area that the patient feels they are ready to change can lead to better adherence and greater achievement of success in the short and longer term. If the patient is uncertain what course to choose, prudence would dictate focusing on control of risk factors that may lead to the most rapid reduction in risk for acute events. For example, blood pressure is both a chronic risk factor and an acute trigger for cardiovascular events. Thus, if a patient has both significant elevations in blood pressure and dyslipidemia, it would be appropriate to focus initial efforts on blood pressure control. Likewise, focus on smoking cessation can lead to more rapid reductions in risk for acute events than some other lifestyle interventions.
PREVENTION AND HEALTH PROMOTION ACROSS THE LIFE COURSE
Periodic Health Evaluations
The “routine annual physical” has in many ways become an expected part of the patient-physician relationship in primary care practice. However, evidence for the efficacy of the periodic health evaluation in asymptomatic adults unselected for risk factors or disease is mixed, and depends on the outcome. Systematic reviews and meta-analyses of published trials have consistently observed lack of benefit (and also lack of harm) in terms of total mortality in association with periodic health evaluations. Data are more heterogeneous but overall suggest no benefit for cancer- or cardiovascular-specific mortality, with the potential for either benefit or harm depending on number of evaluations and patient-level factors. Well-designed studies on non-fatal clinical events and morbidity have been sparsely reported but there appear to be no large effects.
Periodic health evaluations do appear to lead to greater diagnosis of certain conditions such as hypertension and dyslipidemia, as expected. Likewise, periodic health examinations also improve the delivery of recommended preventive services, such as gynecologic examinations and Papanicolaou smears, fecal occult blood testing, and cholesterol screening. The benefits and risks associated with screening tests are discussed in detail in Chap. 4. Risks of routine evaluations include inappropriate or over-testing, or false-positive findings that require follow-up and induce patients to worry. Periodic health examinations appear to be associated with less patient worry. On balance, given the lack of convincing evidence of harm and the potential for better delivery of appropriate screening, counseling, and preventive services, periodic health evaluations appear reasonable for general populations at average risk for chronic conditions.
It is important to note that routine annual comprehensive physical examinations of asymptomatic adult patients have very low yield and may take an inordinate amount of time in a wellness visit. Such time may be better spent on assessing and counseling the patient on other aspects of their health, as discussed below. Evidence-based components that should be included in periodic evaluations focused on health and prevention include a number of age-appropriate screening tests for chronic disease and risk factors, preventive interventions including immunizations and chemoprevention for at-risk individuals, and preventive counseling. The United States Preventive Services Task Force publishes its Guide to Clinical Preventive Services, which contains evidence-based recommendations from the Task Force on preventive services for which there is a high degree of certainty that the service provides at least moderate net clinical benefit (i.e., benefits outweigh harms significantly and to a reasonable magnitude).
Healthy Behaviors and Lifestyles
Owing to the paucity of evidence, the heterogeneity of study designs and the diverse nature of interventions studied, many clinicians are uncertain as to how to deliver advice regarding healthy behaviors and lifestyles. Nevertheless, adverse behaviors and lifestyles contribute to more than 75% of premature, preventable deaths and disability. Estimates from the US National Health and Nutrition Survey indicate that fewer than 1% of Americans achieve an optimal heart-healthy eating pattern. Thus, whereas there are many demands on time during a typical patient-clinician encounter, few things may have more impact on longevity, health and quality of life for asymptomatic patients than an efficient approach to assessing, documenting, and improving patients’ health behaviors. Indeed, the mere act of assessing health behaviors has been shown to affect patient’s health behaviors. Facility with tools for assessment of lifestyle and with strategies for counseling are therefore of paramount importance.
Healthy Eating Patterns
Despite the existence of numerous “fad” diets, and seemingly inconsistent recommendations on dietary composition, there is remarkable agreement about what should constitute a healthy eating pattern for the broad population to avoid nutritional deficits (i.e., vitamin deficiency) and excesses (i.e., excessive caloric intake) and to maximize potential health (Table 2-1, see Chap. 325). Optimal eating patterns consist of whole fruits and vegetables, whole grains, lean proteins, healthy oils, and allow for non-fat or low-fat dairy intake. They tend to exclude frequent ingestion of foods high in refined sugars and starches, saturated fat, and sodium. Since sodium and refined sugars and starches are the hallmark of much of the processed/packaged food supply, a simple rule of thumb is to provide/cook the majority of one’s own meals starting from whole foods and emphasizing fruits and vegetables. Likewise, foods prepared outside of the home tend to have higher fat and sodium content, so special attention to menu choices focused on fruits, vegetables, lean proteins, and whole grains, while minimizing sauces and dressings can help most individuals follow healthier eating patterns. In all cases, sugar-sweetened beverages and non-nutritious snack foods should be minimized. If snacks are included, small amounts of healthy nuts and seeds, or more fruits and vegetables, should be encouraged.
TABLE 2-1
Guidelines and Key Recommendations from the Dietary Guidelines for Americans, 2015–2020
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Specific conditions and diseases, such as diabetes, other metabolic disorders, allergies, and gastrointestinal disorders, may require tailored approaches to diet. In counseling most patients, the general approach should focus on whole foods, eating patterns and appropriate calorie balance, rather than on specific micronutrients such as electrolytes or selected vitamins. It should be remembered that most patients have difficulty understanding nutritional labels on packaged foods, with the attendant demands on numeracy and health literacy.
Dietary guidelines are published by the US Department of Agriculture (USDA) and US Department of Health and Human Services every 5 years, and these guidelines have undergone substantial evolution over time. The current US Dietary Guidelines and Key Recommendations for 2015–2020 are summarized in Table 2-1 and emphasize eating patterns with nutrient-dense (rather than calorie-dense) whole foods, and appropriate caloric intake to achieve and maintain healthy weight. The USDA Guidelines focus on the concept of a healthy plate (rather than the prior food pyramid) for ease of counseling and adoption. Fifty percent of the plate should consist of fruits and vegetables, with remaining portions for whole grains and lean protein foods. When using fat for cooking, it should be done by sauteing in healthier oils (e.g., canola oil), and addition of judicious amounts of healthy raw oils (e.g., olive oil) to dishes is appropriate.
The USDA Guidelines focus on specific healthy eating patterns that adhere to these broad recommendations, and are appropriate for ~97% of the general population. They identify a “Healthy US-Style Eating Pattern” that adheres closely to the evidence-based Dietary Approaches to Stop Hypertension (DASH) eating pattern. Alternative patterns, which vary more in emphasis than in content, include a “Healthy Mediterranean-Style Eating Pattern” and a “Healthy Vegetarian Eating Pattern.”
AGE- AND SEX-SPECIFIC RECOMMENDATIONS
Current dietary recommendations are generally similar for all life stages from ages ≥2 years, but recommended levels of caloric intake (and hence amounts of foods) differ by age, sex, and physical activity level. For example, recommended caloric intake ranges from 1000 calories/d for sedentary 2-year-old children to as high as 3200 calories/d for active 16- to 18-year-old young men. Recommended caloric intakes peak in the early twenties for men and women and gradually decrease over ensuing decades.
As with all lifestyle counseling aimed at behavior change, dietary approaches that partner with the patient and utilize motivational interviewing strategies and shared goals and commitments tend to work best, as described below (see Approach to the Patient).
Physical Activity
Similar to the approach to counseling regarding healthy eating patterns, recommendations on participation in physical activity emphasize the point that any physical activity is better than none. A simple rule of thumb for patients is: “If you are doing nothing, do something; and if you are doing something, do more, every day.” The evidence base for physical activity indicates that the marginal benefits from physical activity are greatest in advancing from no activity to low levels of moderate activity. With increasing duration and intensity of activity, there is a continued curvilinear increase in health benefits, but the marginal gains for each additional minute of moderate-to-vigorous activity slowly diminish. Thus, for adults, the optimal amount of physical activity recommended is 150 min of moderate-intensity or 75 min of vigorous intensity aerobic activity per week, performed in episodes of at least 10 min, and preferably spread throughout the week. Additional health benefits can be realized by engaging in physical activity beyond this amount, and/or by adding muscle-strengthening activities that involve all major muscle groups 2 or more days per week.
In counseling patients regarding physical activity, it is important to note that sedentary time (e.g., seated at work, or at home in front of electronic screens) has adverse health consequences independent of the lack of physical activity during these episodes. Therefore, even modest efforts like standing at the desk and doing gentle stretching for periods during the day may be beneficial. It is also important to emphasize that participating in a variety of aerobic activities (biking, swimming, walking, jogging, rowing, elliptical training, stair-climbing, etc.) can be beneficial and may help to avoid overuse injuries and boredom with the exercise regimen. If patients choose to participate in muscle-strengthening activities for health improvement, emphasis should be placed on weights that allow more repetitions (e.g., 3 sets of 15–20 repetitions that can be performed comfortably, with a rest period in between) and on avoiding breath-holding and straining against a closed glottis.
SUDDEN CARDIAC DEATH RISK
Patients may express concerns regarding the risk of sudden cardiac death during exercise. Whereas the risk of sudden death during exercise does increase directly with the amount of time spent exercising, this association is substantially mitigated by training effects. Thus, patients embarking on an exercise program should be encouraged to increase the duration of aerobic exercise gradually as tolerated, aiming for episodes of at least 30 min 5 times a week as an ideal. Once a comfortable duration is reached, incorporating interval training periods of more intensive activity interspersed during the exercise can provide greater fitness gains.
EXTREME ENDURANCE ACTIVITIES
As with other forms of exercise, extreme endurance activities such as triathlons and marathons should be undertaken only with appropriate and graded training. Such activities tend to take a greater toll on the musculoskeletal system over time than less extreme activities, and they are also associated with measurable damage to the myocardium and greater risks for other organ damage. Athletes participating in endurance activities routinely have elevations in cardiac troponin (a specific circulating marker of myocardial cell damage and death) at the end of the race, although elevations are lower in those who are well trained. Patients and clinicians should consider the patient’s overall health, specific limitations, potential for injury, and ability to train in decision-making regarding participation in endurance events.
AGE-SPECIFIC RECOMMENDATIONS
The US Department of Health and Human Services’ Physical Activity Guidelines for Americans (Table 2-2) recommend that children and adolescents aged 6–17 years should participate in ≥60 min of physical activity daily, most of which should be moderate- or vigorous-intensity aerobic activity, including vigorous activity at least 3 days a week. As noted above, adults aged 18–64 years are recommended to pursue at least 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic activity per week (or equivalent combinations). Adults aged ≥65 years should follow the adult guidelines, or be as active as possible as abilities and conditions allow. Special emphasis is also placed on exercises to improve balance in those at risk for falling.
TABLE 2-2
Recommendations from Physical Activity Guidelines for Americans
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Sleep Hygiene
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Patients often express concerns about the quantity and quality of their sleep. With aging, both aspects of sleep tend to decline, even without overt sleep disorders. Documentation of sleep using a sleep log may assist in understanding different types of insomnia and sleep disorders. Encouraging daily activity to promote fatigue, avoidance of eating and drinking alcohol too close to bedtime, and regular daily sleep habits may help patients achieve better sleep. Regular use of sedative medications should generally be discouraged given the high potential for dependence, addiction, and altered sleep quality.
DISORDERS OF SLEEP
The prevalence of sleep-related breathing disorders, including obstructive sleep apnea (OSA), is poorly documented. Based on data from the 1990s, the prevalence of diagnosed mild OSA in the US population was ~10%, and of moderate to severe apnea was ~5%. However, the increasing prevalence of obesity, a major risk factor for OSA, suggests that the prevalence may have increased. The prevalence of asymptomatic or undiagnosed sleep apnea is unknown. Patients with persistent complaints of poor sleep quality, excessive daytime somnolence, or with witnessed apneic spells may benefit from screening for sleep disorders, prior to consideration of a formal sleep study. A number of clinical tools have been developed to screen for sleep apnea, including the Epworth Sleepiness Scale, the STOP (Snoring, Tiredness, Observed apnea, high blood Pressure) Questionnaire, and the STOP-Bang Questionnaire (STOP plus assessment of body mass index, age, neck circumference, and gender), among others. The US Preventive Services Task Force found that current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults owing to a lack of validation data in primary care settings. Nonetheless, the high prevalence and significant health consequences of sleep apnea suggest that clinicians should be alert for its potential presence, particularly in patients who are obese with symptoms of excessive daytime somnolence or witnessed apnea episodes. Other sleep disorders, such as restless leg syndrome, may be identified with simple history.
Weight Management
Overweight and obesity are prevalent in epidemic proportions in the US and other industrialized nations (Chaps. 394, 395). Since 1985, the prevalence of obesity in the United States has increased from ~10% to almost 35%, and the prevalence of overweight is now ~40%. Overweight and obesity disproportionately affect individuals in lower socio-economic strata, and in many underserved minority populations, including African Americans, Latino Americans, and American Indians. In all race-ethnic groups, both overweight and obesity are associated with adverse health consequences, including diabetes, certain cancers, cardiovascular diseases, and degenerative joint disease. Eating disorders such as anorexia and bulimia are much less common but pose major health consequences for affected patients, and should be suspected particularly in younger women with history of rapid weight shifts or underweight status.
Weight loss is one of the most difficult preventive interventions to achieve and sustain over time. However, several key factors can assist the patient and clinician, and early referral to a dietician can be very helpful. The first therapeutic goal is to aim for weight stabilization. Many of the risks of overweight and obesity are driven more strongly by continued weight gain, rather than overweight/obese status per se. Working with the patient to find initial strategies for weight maintenance can be a successful initial step with success for many patients. For those who can progress to considering weight loss, it is critical to help the patient understand that there is no standard solution. Experimentation and documentation are key. Tools to assist patients can include food and weight logs, activity logs, and smart phone apps. Some patients respond best to structured commercial dietary programs where meals are provided to them. Any of these approaches can be tried with or without social group supports.
The key construct for weight loss is, of course, negative calorie balance. This is achieved through a combination of reduced caloric intake and increased physical activity. Patients may already understand, from prior weight loss attempts, what combination works best for them to achieve this. Some patients find that they cannot lose weight without increasing their exercise. For many, reduction of caloric intake is most efficient. Encouraging the patient to find what works for them is most important. The same principle holds for dietary content. Well done feeding studies indicate that weigh loss is dependent far more on the reduction of caloric intake than on the relative composition of fat, protein and carbohydrate in the diet. There may be other medical reasons to choose one approach over another, but if not, encouraging the patient to pick one approach and document the results is an important start.
Tobacco Cessation
Escaping nicotine dependence is another major, but critical, challenge to prevention and wellness efforts (see Chap. 448). The addictive effects of nicotine have been well documented, with effects that can last for years after successful cessation. Assessing a patient’s past history of cessation attempts and current readiness for change are key first steps in forging a successful approach. Frequent follow-up and reinforcement, as well as use of nicotine replacement therapy and other cessation-promoting medications are additional critical elements. Recidivism is the rule, and patients should expect to resume smoking and attempt again as they journey to tobacco cessation.
MENTAL HEALTH AND ADDICTION
Assessment for depression and cognitive impairment are important to address when patients exhibit symptoms, or they or their family members express concerns. Both of these common conditions play a major role in reducing quality of life and are high on patients’ lists of concerns, even if not clearly expressed. Screening tools for depression are reviewed in Chap. 444. Cognitive function decline with aging or comorbid illness, including depression, should be anticipated. Assessment tools such as the General Practitioner Assessment of Cognition or the Mini-CogTM test are widely available and effective rapid assessment tools.
Alcohol and Opioids
Alcohol dependence and abuse are common and underdiagnosed (see Chaps. 445, 446). Rapid screening tools have proven efficacy for identifying patients with alcohol problems. In a systematic review, the CAGE (cut down, guilty, annoyed, eye opener) questionnaire was most effective at identifying alcohol abuse and dependence, with reasonable sensitivity and high specificity. The present opioid epidemic in the United States presents a new and substantial public health challenge given the high potential for dependency and abuse of these drugs. Rapid screening tools are being developed and validated to assist clinicians in screening for opioid dependence.
ACCIDENTS AND SUICIDE
Regular assessment of patient safety through simple questions about seat belt use, domestic violence, and gun safety in the home continue to be important parts of health promotion and wellness. Longstanding recommendations for assessment of suicidal ideation among patients with depression or a history of suicide attempts also continue to be relevant.
APPROACH TO THE PATIENT
APPROACH TO THE PATIENT
In the context of a clinical visit focused on health assessment, health promotion, and prevention, the basic skills of history taking are of paramount importance. Much of the evaluation, counseling, and management that focus on health promotion and prevention also require engagement and buy-in from the patient in order to assist with recognition of contributing behaviors and to promote adherence to therapeutic plans. Therefore, in addition to standard history-taking, additional skills such as motivational interviewing and eliciting patient commitments and contracting may prove of significant value. The availability of additional tools to assist with screening and chronic management, both online and through mobile health technologies, is rapidly expanding, with uncertain implications for the future. Major research gaps exist in our understanding of how best to employ these newer technologies to improve health outcomes. Concepts of behavioral economics are being explored to better understand the psychology of decision-making and incentives as a means to improve lifestyle choices and adherence to treatment plans (Chap. 468).
The limited time available to clinicians and patients during a wellness visit or periodic health examination (not driven by specific patient issues) makes it important to prioritize assessment and counseling for factors that affect longevity, healthspan, and quality of life over approaches that may have low yield, such as the annual comprehensive physical examination in an asymptomatic patient. Setting clear expectations for the content of a wellness visit may be a first step, and scheduling follow-up visits for findings or to continue indicated counseling are important steps to achieving better health outcomes.
Donald M. Lloyd-Jones; Kathleen M. McKibbin
GOALS AND APPROACHES TO PREVENTION
HEALTH PROMOTION
PRIORITIZING PREVENTION STRATEGIES
PREVENTION AND HEALTH PROMOTION ACROSS THE LIFE COURSE
Periodic Health Evaluations
Healthy Behaviors and Lifestyles
Healthy Eating Patterns
Physical Activity
Sleep Hygiene
Weight Management
Tobacco Cessation
MENTAL HEALTH AND ADDICTION
Alcohol and Opioids
ACCIDENTS AND SUICIDE
APPROACH TO THE PATIENT
GOALS AND APPROACHES TO PREVENTION
Prevention of acute and chronic diseases before their onset has been recognized as one of the hallmarks of excellent medical practice for centuries, and is now used as a metric for highly functioning healthcare systems. The ultimate goal of preventive strategies is to avoid premature death. However, as longevity has increased dramatically worldwide over the last century (largely as a result of public health practices), increasing emphasis is placed on prevention for the purpose of preserving quality of life and extending the healthspan, not just the lifespan. Given that all patients will eventually die, the goal of prevention ultimately becomes compression of morbidity toward the end of the lifespan; that is, reduction of the amount of burden and time spent with disease prior to dying. As shown in Fig. 2-1, normative aging tends to involve a steady decline in the stock of health, with accelerating decline over time. Successful prevention offers the opportunity both to extend life and to extend healthy life, thus “squaring the curve” of health loss during aging.
FIGURE 2-1
Loss of health with aging. Representation of normative aging with loss of the full stock of health with which individuals are born (indicating gain of morbidity), contrasted with a squared curve with greater longevity and fuller stock of health (less morbidity) until shortly before death. The “squared curve” represents the likely ideal situation for most patients.
The image shows a graph depicting loss of health with aging contrasted with a squared curve with greater longevity and less morbidity by prevention.
View Full Size| Favorite Figure|Download Slide (.ppt)
Prevention strategies have been characterized as tertiary, secondary, primary, and primordial. Tertiary prevention requires rapid action to prevent imminent death in the setting of acute illness, such as through percutaneous coronary intervention in the setting of ST-segment elevation myocardial infarction. Secondary prevention strategies focus on avoiding the recurrence of disease and death in an individual who is already affected. For example, tamoxifen is recommended for women with surgically treated early-stage, estrogen-receptor-positive breast cancer, because it reduces the risk of recurrent breast cancer (including in the contralateral breast) and death. Primary prevention attempts to reduce the risk of incident disease among individuals with a risk factor. Treatment of elevated blood pressure in individuals who have not yet experienced cardiovascular disease represents one example of primary prevention that has proven effective in reducing the incidence of stroke, heart failure, and coronary heart disease.
Primordial prevention is a more recent concept (first introduced in 1979) which focuses on prevention of the development of risk factors for disease, not just prevention of disease. Primordial prevention strategies emphasize upstream determinants of risk for chronic diseases, such as eating patterns, physical activity, and environmental and social determinants of health. It therefore encompasses medical treatment strategies for individuals as well as a strong reliance on public health and social policy. It is increasingly clear that primordial prevention represents the ultimate means for reducing the burden of chronic diseases of aging. Once risk factors develop, it is difficult to restore risk to the low level of someone who never developed the risk factor. The time spent with adverse levels of the risk factor often causes irreversible damage that precludes complete restoration of low risk. For example, individuals with hypertension who are treated back to optimal levels (<120 a="" abolish="" age="" all="" also="" and="" antihypertensive="" as="" atherosclerosis="" be="" below="" blood="" burden="" but="" cannot="" cardiovascular="" comorbid="" compared="" compression="" conversely="" damage="" described="" despite="" detail="" developing="" disease="" do="" efficacious="" elevated="" essentially="" events="" evidence="" factors="" fully="" function="" greater="" have="" having="" hypertension="" illnesses="" in="" index="" individuals="" into="" is="" left="" levels="" lifetime="" living="" longer="" lower="" maintain="" maintained="" major="" mass="" medications.="" middle="" mmhg="" morbidity="" more="" of="" optimal="" organ="" other="" p="" patients="" pressure="" prevention="" primordial="" renal="" result="" reversed="" risk="" spent="" still="" subsequently="" substantially="" such="" target="" that="" the="" their="" therapy="" they="" those="" through="" time="" treated="" twice="" untreated="" ventricular="" while="" who="" with="" without="" worse="">
Prevention strategies should be distinguished from disease screening strategies. Screening attempts to detect evidence of disease at its earliest stages, when treatment is likely to be more efficacious than for advanced disease (Chap. 4). Screening can be performed in service of prevention, especially if it aids in identifying pre-clinical markers associated with elevated disease risk.
HEALTH PROMOTION
In recent decades, medical practice has increasingly focused on public health approaches to promote health, and not just prevent disease. Prevention of disease is a worthy individual and societal goal in and of itself, but it does not necessarily guarantee health. Health is a broader construct encompassing more than just absence of disease. It includes biological, physiological, and psychological domains (among others) in a continuum, rather than occurring as a dichotomous trait. Health is therefore somewhat subjective, but attempts have been made to use more objective criteria to define health in order to raise awareness, prevent disease, and promote healthy longevity.
For example, in 2010 the American Heart Association (AHA) defined a new construct of “cardiovascular health” based on evidence of associations with longevity, disease avoidance, healthy longevity, and quality of life. The definition of cardiovascular health is based on seven health behaviors and health factors (eating pattern, physical activity, body mass, smoking status, and levels of blood pressure, blood cholesterol, and blood glucose) and includes a spectrum from poor to ideal. Individuals with optimal levels of all seven metrics simultaneously are considered to have ideal cardiovascular health. The state of cardiovascular health for an individual or a population can be assessed with simple scoring by counting the number of ideal metrics (out of 7) or applying 0 points for each poor metric, 1 point for each intermediate metric, and 2 points for each ideal metric, thus creating a composite cardiovascular health score ranging from 0 to 14 points. Higher cardiovascular health scores in younger and middle ages have been associated with greater longevity, lower incidence of cardiovascular disease, lower incidence of other chronic diseases of aging (including dementia, cancer, and more), compression of morbidity, greater quality of life, and lower healthcare costs, achieving both individual and societal goals for healthy aging, and further establishing the critical importance of primordial prevention and cardiovascular health promotion.
Focusing on health promotion, rather than just disease prevention, may also provide greater motivation for patients to pursue lifestyle changes or adhere to clinician recommendations. Extensive literature suggests that providing patients solely with information regarding disease risk, or risk reduction with treatment, is unlikely to motivate desired behavior change. Empowering patients with strategies to achieve positive health goals after discussing risks can provide more effective adherence and better long-term outcomes. In the case of smoking cessation, enumerating only the risks of smoking can lead to patient inertia and therapeutic nihilism, and has proven an ineffective approach, whereas strategies that incorporate positive health messaging, support and feedback, with appropriate use of evidence-based therapies, have proven far more effective.
PRIORITIZING PREVENTION STRATEGIES
In secondary prevention, the patient already has manifest clinical disease, and is therefore at high risk for progression. The approach should be to work with the patient to implement all evidence-based strategies that will help to prevent recurrence or progression. This will typically include drug therapy as well as therapeutic lifestyle changes to control ongoing risk factors which may have caused disease in the first place. Juggling priorities can be difficult, and barriers to implementation are many, including costs, time, patient health literacy, and patient and caregiver capacity to organize the regimen. Addressing these potential barriers with the patient can help to forge a therapeutic bond and may improve adherence; ignoring them will likely lead to therapeutic failure. Numerous studies demonstrate that, even in high-functioning health systems, only ~50% of patients are taking recommended, evidence-based secondary prevention medications, such as statins, by 1 year after a myocardial infarction.
In patients who are eligible for primary prevention strategies, it is important to frame the discussion around the overall evidence base as well as an individual patient’s likelihood of benefit from a given preventive intervention. A first step is to understand the patient’s estimated absolute risk for disease in the foreseeable future, or during their remaining lifespan. However, absolute risk estimation and presentation of those risks is generally insufficient to motivate behavior change. It is critical to assess the patient’s understanding and tolerance of the risk, their readiness to implement lifestyle changes or adhere to drug therapy, and their overall preferences regarding use of drug therapy to prevent an event (e.g., cancer, myocardial infarction, stroke). The clinician can help the patient by informing them of the risks for disease and potential for absolute benefits (and harms) from the available evidence-based choices. This may take more than one conversation, but given that diseases, such as cancer and cardiovascular disease, are the leading causes of premature death and disability, the time is well spent.
Partnering with the patient through motivational interviewing may assist in the process of selecting initial approaches to prevention. Selecting an area that the patient feels they are ready to change can lead to better adherence and greater achievement of success in the short and longer term. If the patient is uncertain what course to choose, prudence would dictate focusing on control of risk factors that may lead to the most rapid reduction in risk for acute events. For example, blood pressure is both a chronic risk factor and an acute trigger for cardiovascular events. Thus, if a patient has both significant elevations in blood pressure and dyslipidemia, it would be appropriate to focus initial efforts on blood pressure control. Likewise, focus on smoking cessation can lead to more rapid reductions in risk for acute events than some other lifestyle interventions.
PREVENTION AND HEALTH PROMOTION ACROSS THE LIFE COURSE
Periodic Health Evaluations
The “routine annual physical” has in many ways become an expected part of the patient-physician relationship in primary care practice. However, evidence for the efficacy of the periodic health evaluation in asymptomatic adults unselected for risk factors or disease is mixed, and depends on the outcome. Systematic reviews and meta-analyses of published trials have consistently observed lack of benefit (and also lack of harm) in terms of total mortality in association with periodic health evaluations. Data are more heterogeneous but overall suggest no benefit for cancer- or cardiovascular-specific mortality, with the potential for either benefit or harm depending on number of evaluations and patient-level factors. Well-designed studies on non-fatal clinical events and morbidity have been sparsely reported but there appear to be no large effects.
Periodic health evaluations do appear to lead to greater diagnosis of certain conditions such as hypertension and dyslipidemia, as expected. Likewise, periodic health examinations also improve the delivery of recommended preventive services, such as gynecologic examinations and Papanicolaou smears, fecal occult blood testing, and cholesterol screening. The benefits and risks associated with screening tests are discussed in detail in Chap. 4. Risks of routine evaluations include inappropriate or over-testing, or false-positive findings that require follow-up and induce patients to worry. Periodic health examinations appear to be associated with less patient worry. On balance, given the lack of convincing evidence of harm and the potential for better delivery of appropriate screening, counseling, and preventive services, periodic health evaluations appear reasonable for general populations at average risk for chronic conditions.
It is important to note that routine annual comprehensive physical examinations of asymptomatic adult patients have very low yield and may take an inordinate amount of time in a wellness visit. Such time may be better spent on assessing and counseling the patient on other aspects of their health, as discussed below. Evidence-based components that should be included in periodic evaluations focused on health and prevention include a number of age-appropriate screening tests for chronic disease and risk factors, preventive interventions including immunizations and chemoprevention for at-risk individuals, and preventive counseling. The United States Preventive Services Task Force publishes its Guide to Clinical Preventive Services, which contains evidence-based recommendations from the Task Force on preventive services for which there is a high degree of certainty that the service provides at least moderate net clinical benefit (i.e., benefits outweigh harms significantly and to a reasonable magnitude).
Healthy Behaviors and Lifestyles
Owing to the paucity of evidence, the heterogeneity of study designs and the diverse nature of interventions studied, many clinicians are uncertain as to how to deliver advice regarding healthy behaviors and lifestyles. Nevertheless, adverse behaviors and lifestyles contribute to more than 75% of premature, preventable deaths and disability. Estimates from the US National Health and Nutrition Survey indicate that fewer than 1% of Americans achieve an optimal heart-healthy eating pattern. Thus, whereas there are many demands on time during a typical patient-clinician encounter, few things may have more impact on longevity, health and quality of life for asymptomatic patients than an efficient approach to assessing, documenting, and improving patients’ health behaviors. Indeed, the mere act of assessing health behaviors has been shown to affect patient’s health behaviors. Facility with tools for assessment of lifestyle and with strategies for counseling are therefore of paramount importance.
Healthy Eating Patterns
Despite the existence of numerous “fad” diets, and seemingly inconsistent recommendations on dietary composition, there is remarkable agreement about what should constitute a healthy eating pattern for the broad population to avoid nutritional deficits (i.e., vitamin deficiency) and excesses (i.e., excessive caloric intake) and to maximize potential health (Table 2-1, see Chap. 325). Optimal eating patterns consist of whole fruits and vegetables, whole grains, lean proteins, healthy oils, and allow for non-fat or low-fat dairy intake. They tend to exclude frequent ingestion of foods high in refined sugars and starches, saturated fat, and sodium. Since sodium and refined sugars and starches are the hallmark of much of the processed/packaged food supply, a simple rule of thumb is to provide/cook the majority of one’s own meals starting from whole foods and emphasizing fruits and vegetables. Likewise, foods prepared outside of the home tend to have higher fat and sodium content, so special attention to menu choices focused on fruits, vegetables, lean proteins, and whole grains, while minimizing sauces and dressings can help most individuals follow healthier eating patterns. In all cases, sugar-sweetened beverages and non-nutritious snack foods should be minimized. If snacks are included, small amounts of healthy nuts and seeds, or more fruits and vegetables, should be encouraged.
TABLE 2-1
Guidelines and Key Recommendations from the Dietary Guidelines for Americans, 2015–2020
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Specific conditions and diseases, such as diabetes, other metabolic disorders, allergies, and gastrointestinal disorders, may require tailored approaches to diet. In counseling most patients, the general approach should focus on whole foods, eating patterns and appropriate calorie balance, rather than on specific micronutrients such as electrolytes or selected vitamins. It should be remembered that most patients have difficulty understanding nutritional labels on packaged foods, with the attendant demands on numeracy and health literacy.
Dietary guidelines are published by the US Department of Agriculture (USDA) and US Department of Health and Human Services every 5 years, and these guidelines have undergone substantial evolution over time. The current US Dietary Guidelines and Key Recommendations for 2015–2020 are summarized in Table 2-1 and emphasize eating patterns with nutrient-dense (rather than calorie-dense) whole foods, and appropriate caloric intake to achieve and maintain healthy weight. The USDA Guidelines focus on the concept of a healthy plate (rather than the prior food pyramid) for ease of counseling and adoption. Fifty percent of the plate should consist of fruits and vegetables, with remaining portions for whole grains and lean protein foods. When using fat for cooking, it should be done by sauteing in healthier oils (e.g., canola oil), and addition of judicious amounts of healthy raw oils (e.g., olive oil) to dishes is appropriate.
The USDA Guidelines focus on specific healthy eating patterns that adhere to these broad recommendations, and are appropriate for ~97% of the general population. They identify a “Healthy US-Style Eating Pattern” that adheres closely to the evidence-based Dietary Approaches to Stop Hypertension (DASH) eating pattern. Alternative patterns, which vary more in emphasis than in content, include a “Healthy Mediterranean-Style Eating Pattern” and a “Healthy Vegetarian Eating Pattern.”
AGE- AND SEX-SPECIFIC RECOMMENDATIONS
Current dietary recommendations are generally similar for all life stages from ages ≥2 years, but recommended levels of caloric intake (and hence amounts of foods) differ by age, sex, and physical activity level. For example, recommended caloric intake ranges from 1000 calories/d for sedentary 2-year-old children to as high as 3200 calories/d for active 16- to 18-year-old young men. Recommended caloric intakes peak in the early twenties for men and women and gradually decrease over ensuing decades.
As with all lifestyle counseling aimed at behavior change, dietary approaches that partner with the patient and utilize motivational interviewing strategies and shared goals and commitments tend to work best, as described below (see Approach to the Patient).
Physical Activity
Similar to the approach to counseling regarding healthy eating patterns, recommendations on participation in physical activity emphasize the point that any physical activity is better than none. A simple rule of thumb for patients is: “If you are doing nothing, do something; and if you are doing something, do more, every day.” The evidence base for physical activity indicates that the marginal benefits from physical activity are greatest in advancing from no activity to low levels of moderate activity. With increasing duration and intensity of activity, there is a continued curvilinear increase in health benefits, but the marginal gains for each additional minute of moderate-to-vigorous activity slowly diminish. Thus, for adults, the optimal amount of physical activity recommended is 150 min of moderate-intensity or 75 min of vigorous intensity aerobic activity per week, performed in episodes of at least 10 min, and preferably spread throughout the week. Additional health benefits can be realized by engaging in physical activity beyond this amount, and/or by adding muscle-strengthening activities that involve all major muscle groups 2 or more days per week.
In counseling patients regarding physical activity, it is important to note that sedentary time (e.g., seated at work, or at home in front of electronic screens) has adverse health consequences independent of the lack of physical activity during these episodes. Therefore, even modest efforts like standing at the desk and doing gentle stretching for periods during the day may be beneficial. It is also important to emphasize that participating in a variety of aerobic activities (biking, swimming, walking, jogging, rowing, elliptical training, stair-climbing, etc.) can be beneficial and may help to avoid overuse injuries and boredom with the exercise regimen. If patients choose to participate in muscle-strengthening activities for health improvement, emphasis should be placed on weights that allow more repetitions (e.g., 3 sets of 15–20 repetitions that can be performed comfortably, with a rest period in between) and on avoiding breath-holding and straining against a closed glottis.
SUDDEN CARDIAC DEATH RISK
Patients may express concerns regarding the risk of sudden cardiac death during exercise. Whereas the risk of sudden death during exercise does increase directly with the amount of time spent exercising, this association is substantially mitigated by training effects. Thus, patients embarking on an exercise program should be encouraged to increase the duration of aerobic exercise gradually as tolerated, aiming for episodes of at least 30 min 5 times a week as an ideal. Once a comfortable duration is reached, incorporating interval training periods of more intensive activity interspersed during the exercise can provide greater fitness gains.
EXTREME ENDURANCE ACTIVITIES
As with other forms of exercise, extreme endurance activities such as triathlons and marathons should be undertaken only with appropriate and graded training. Such activities tend to take a greater toll on the musculoskeletal system over time than less extreme activities, and they are also associated with measurable damage to the myocardium and greater risks for other organ damage. Athletes participating in endurance activities routinely have elevations in cardiac troponin (a specific circulating marker of myocardial cell damage and death) at the end of the race, although elevations are lower in those who are well trained. Patients and clinicians should consider the patient’s overall health, specific limitations, potential for injury, and ability to train in decision-making regarding participation in endurance events.
AGE-SPECIFIC RECOMMENDATIONS
The US Department of Health and Human Services’ Physical Activity Guidelines for Americans (Table 2-2) recommend that children and adolescents aged 6–17 years should participate in ≥60 min of physical activity daily, most of which should be moderate- or vigorous-intensity aerobic activity, including vigorous activity at least 3 days a week. As noted above, adults aged 18–64 years are recommended to pursue at least 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic activity per week (or equivalent combinations). Adults aged ≥65 years should follow the adult guidelines, or be as active as possible as abilities and conditions allow. Special emphasis is also placed on exercises to improve balance in those at risk for falling.
TABLE 2-2
Recommendations from Physical Activity Guidelines for Americans
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Sleep Hygiene
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Patients often express concerns about the quantity and quality of their sleep. With aging, both aspects of sleep tend to decline, even without overt sleep disorders. Documentation of sleep using a sleep log may assist in understanding different types of insomnia and sleep disorders. Encouraging daily activity to promote fatigue, avoidance of eating and drinking alcohol too close to bedtime, and regular daily sleep habits may help patients achieve better sleep. Regular use of sedative medications should generally be discouraged given the high potential for dependence, addiction, and altered sleep quality.
DISORDERS OF SLEEP
The prevalence of sleep-related breathing disorders, including obstructive sleep apnea (OSA), is poorly documented. Based on data from the 1990s, the prevalence of diagnosed mild OSA in the US population was ~10%, and of moderate to severe apnea was ~5%. However, the increasing prevalence of obesity, a major risk factor for OSA, suggests that the prevalence may have increased. The prevalence of asymptomatic or undiagnosed sleep apnea is unknown. Patients with persistent complaints of poor sleep quality, excessive daytime somnolence, or with witnessed apneic spells may benefit from screening for sleep disorders, prior to consideration of a formal sleep study. A number of clinical tools have been developed to screen for sleep apnea, including the Epworth Sleepiness Scale, the STOP (Snoring, Tiredness, Observed apnea, high blood Pressure) Questionnaire, and the STOP-Bang Questionnaire (STOP plus assessment of body mass index, age, neck circumference, and gender), among others. The US Preventive Services Task Force found that current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults owing to a lack of validation data in primary care settings. Nonetheless, the high prevalence and significant health consequences of sleep apnea suggest that clinicians should be alert for its potential presence, particularly in patients who are obese with symptoms of excessive daytime somnolence or witnessed apnea episodes. Other sleep disorders, such as restless leg syndrome, may be identified with simple history.
Weight Management
Overweight and obesity are prevalent in epidemic proportions in the US and other industrialized nations (Chaps. 394, 395). Since 1985, the prevalence of obesity in the United States has increased from ~10% to almost 35%, and the prevalence of overweight is now ~40%. Overweight and obesity disproportionately affect individuals in lower socio-economic strata, and in many underserved minority populations, including African Americans, Latino Americans, and American Indians. In all race-ethnic groups, both overweight and obesity are associated with adverse health consequences, including diabetes, certain cancers, cardiovascular diseases, and degenerative joint disease. Eating disorders such as anorexia and bulimia are much less common but pose major health consequences for affected patients, and should be suspected particularly in younger women with history of rapid weight shifts or underweight status.
Weight loss is one of the most difficult preventive interventions to achieve and sustain over time. However, several key factors can assist the patient and clinician, and early referral to a dietician can be very helpful. The first therapeutic goal is to aim for weight stabilization. Many of the risks of overweight and obesity are driven more strongly by continued weight gain, rather than overweight/obese status per se. Working with the patient to find initial strategies for weight maintenance can be a successful initial step with success for many patients. For those who can progress to considering weight loss, it is critical to help the patient understand that there is no standard solution. Experimentation and documentation are key. Tools to assist patients can include food and weight logs, activity logs, and smart phone apps. Some patients respond best to structured commercial dietary programs where meals are provided to them. Any of these approaches can be tried with or without social group supports.
The key construct for weight loss is, of course, negative calorie balance. This is achieved through a combination of reduced caloric intake and increased physical activity. Patients may already understand, from prior weight loss attempts, what combination works best for them to achieve this. Some patients find that they cannot lose weight without increasing their exercise. For many, reduction of caloric intake is most efficient. Encouraging the patient to find what works for them is most important. The same principle holds for dietary content. Well done feeding studies indicate that weigh loss is dependent far more on the reduction of caloric intake than on the relative composition of fat, protein and carbohydrate in the diet. There may be other medical reasons to choose one approach over another, but if not, encouraging the patient to pick one approach and document the results is an important start.
Tobacco Cessation
Escaping nicotine dependence is another major, but critical, challenge to prevention and wellness efforts (see Chap. 448). The addictive effects of nicotine have been well documented, with effects that can last for years after successful cessation. Assessing a patient’s past history of cessation attempts and current readiness for change are key first steps in forging a successful approach. Frequent follow-up and reinforcement, as well as use of nicotine replacement therapy and other cessation-promoting medications are additional critical elements. Recidivism is the rule, and patients should expect to resume smoking and attempt again as they journey to tobacco cessation.
MENTAL HEALTH AND ADDICTION
Assessment for depression and cognitive impairment are important to address when patients exhibit symptoms, or they or their family members express concerns. Both of these common conditions play a major role in reducing quality of life and are high on patients’ lists of concerns, even if not clearly expressed. Screening tools for depression are reviewed in Chap. 444. Cognitive function decline with aging or comorbid illness, including depression, should be anticipated. Assessment tools such as the General Practitioner Assessment of Cognition or the Mini-CogTM test are widely available and effective rapid assessment tools.
Alcohol and Opioids
Alcohol dependence and abuse are common and underdiagnosed (see Chaps. 445, 446). Rapid screening tools have proven efficacy for identifying patients with alcohol problems. In a systematic review, the CAGE (cut down, guilty, annoyed, eye opener) questionnaire was most effective at identifying alcohol abuse and dependence, with reasonable sensitivity and high specificity. The present opioid epidemic in the United States presents a new and substantial public health challenge given the high potential for dependency and abuse of these drugs. Rapid screening tools are being developed and validated to assist clinicians in screening for opioid dependence.
ACCIDENTS AND SUICIDE
Regular assessment of patient safety through simple questions about seat belt use, domestic violence, and gun safety in the home continue to be important parts of health promotion and wellness. Longstanding recommendations for assessment of suicidal ideation among patients with depression or a history of suicide attempts also continue to be relevant.
APPROACH TO THE PATIENT
APPROACH TO THE PATIENT
In the context of a clinical visit focused on health assessment, health promotion, and prevention, the basic skills of history taking are of paramount importance. Much of the evaluation, counseling, and management that focus on health promotion and prevention also require engagement and buy-in from the patient in order to assist with recognition of contributing behaviors and to promote adherence to therapeutic plans. Therefore, in addition to standard history-taking, additional skills such as motivational interviewing and eliciting patient commitments and contracting may prove of significant value. The availability of additional tools to assist with screening and chronic management, both online and through mobile health technologies, is rapidly expanding, with uncertain implications for the future. Major research gaps exist in our understanding of how best to employ these newer technologies to improve health outcomes. Concepts of behavioral economics are being explored to better understand the psychology of decision-making and incentives as a means to improve lifestyle choices and adherence to treatment plans (Chap. 468).
The limited time available to clinicians and patients during a wellness visit or periodic health examination (not driven by specific patient issues) makes it important to prioritize assessment and counseling for factors that affect longevity, healthspan, and quality of life over approaches that may have low yield, such as the annual comprehensive physical examination in an asymptomatic patient. Setting clear expectations for the content of a wellness visit may be a first step, and scheduling follow-up visits for findings or to continue indicated counseling are important steps to achieving better health outcomes.
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