Periodic Health Examination

A wide range of tests and procedures may be offered as part of a PHE. Physicians and other health care workers have a responsibility to promote only those elements for which there is evidence of more benefit than harm. In North America, two parallel organizations, The Canadian Task Force on Preventive Health Care and the U.S. Preventive Services Task Force, use a rigorous process to weigh the scientific evidence, and they then recommend to physicians whether specific procedures should be included or excluded from the PHE. Other authoritative bodies and societies also issue recommendations, but conflicting recommendations can cause confusion among physicians and consumers of health care. The following elements are commonly included in the PHE.

Counseling. Counseling involves a discussion with an individual to provide advice and encouragement towards a particular behavior. Tobacco use is regarded as one of the most important modifiable risk factors for a wide variety of diseases, including lung cancer, chronic bronchitis, heart disease, strokes, and peripheral vascular disease. Counseling individuals about their smoking practices is effective for reducing the risk of subsequent illness. This advice may be supplemented by additional antismoking aids, such as the use of nicotine patches or gum.

Many individuals in North America, and in the Western world, have unhealthy diets. An excess of saturated fat and inadequate amounts of fibre and calcium are frequent. Counseling to take up a more prudent diet (total fat less than 30 percent of daily intake), increased consumption of fibre (more than 20 grams per day), and 1200–1500 grams of calcium per day is frequently part of the PHE. Advice may also be offered concerning the use of supplemental vitamins and minerals.

Many older individuals have an inactive lifestyle. There is ample evidence that even modest amounts of exercise improve well-being, muscle strength, bone integrity, and cardiovascular fitness. Individuals are therefore often advised to take up some form of aerobic exercise, such as walking, bicycling, or swimming. Counseling Table 1 Elements of the Periodic Health Examination SOURCE: Author about safety in driving a motor vehicle usually stresses the importance of wearing seat belts and avoidance of alcohol. While small amounts of alcohol have been shown to benefit cardiovascular health, excessive consumption of alcohol is injurious to health. Advice concerning judicious use of alcohol is usually offered together with questions to detect excessive drinking. The risk of injury in the home may also be discussed. Such risks can be minimized by eliminating objects on the floor (e.g., scatter rugs), ensuring correct hot water temperature (49°C, or 120°F) and adequate lighting on stairs and other hazardous areas.

Inoculations. Annual strain-specific influenza inoculations reduce the risk of influenza and reduce mortality and disability from this condition. Influenza inoculations are recommended for all older individuals. Pneumococcal inoculations reduce the risk of pneumonia and other infections caused by the pneumococcus bacteria. This inoculation is usually given every ten years. Although tetanus is very rare in older people, some physicians recommend maintaining immunity with periodic inoculations.

Risk factors for cardiovascular disease. Modifiable risk factors for cardiovascular disease include high blood pressure (hypertension), elevated levels of cholesterol and other lipids (fats), tobacco smoking, and elevated blood-sugar levels (diabetes mellitus). All older individuals should have their blood pressure measured regularly. Treatment for hypertension is usually initiated when the systolic (higher reading) is above 160 (and sometimes 140) or the diastolic (lower reading) is above 90. Older individuals who are at increased risk of heart disease (smokers, diabetics, and those with high blood pressure, strong family history, or symptoms of heart disease) should have blood tests to measure blood cholesterol and lipid levels. Individuals at high risk of diabetes (e.g., overweight, family history) will usually be offered a test for blood-sugar level. Not all of these tests will be required for every older person, and there is some disagreement among authorities about which tests are advisable.

Early detection of malignant diseases. Mammography (breast X rays) and physical examination of the breasts at regular intervals (usually two years) have been shown to reduce deaths from breast cancer. Screening for colorectal (bowel) cancer with stool testing for blood or endoscopy (examining the bowel with a flexible instrument) can reduce the risk of deaths from cancer. Papanicolaou (Pap) test screening of the cervix (neck of the womb) can detect changes that may lead to subsequent cancer. Regular screening for these three cancers is recommended by almost all authorities. Examination of the skin is usually performed to detect changes that may develop into cancer. Tests to detect cancer of the prostate gland are also available, though it is not yet clear whether these tests should be regularly performed on older men.

Screening of special senses. Approximately one-third of older people have difficulty hearing, though they may not be aware of it. A hearing test is recommended as part of the PHE, as is a test of eyesight using a Sight Card (letters of diminishing size) viewed at a fixed distance.

Counseling about hormone replacement. There is mounting evidence that estrogen hormone replacement for women after menopause reduces the risk of osteoporosis, menopausal symptoms, and possibly Alzheimer's disease. Balanced against these benefits is a very slight increased risk of breast cancer with prolonged use of estrogens. There is conflicting evidence on the effects of estrogen replacement on the risk of heart disease. The PHE should therefore include a discussion of hormone replacement therapy and assessment of individual risk prior to a shared decision being made by a woman and her physician.

Miscellaneous conditions. Early detection of physical disabilities (e.g., difficulties walking, climbing stairs, dressing) may be beneficial, as appropriate therapy and additional supports may reduce subsequent disability. Simple tests to detect physical disability are available. Memory tests and inquiry of caregivers about memory problems may be included in the PHE, although the value of such screening remains debatable. For individuals at high risk of osteoporosis (e.g., family history, small frame, female gender, previous fractures), tests for bone density may be offered. Screening for abdominal aortic aneurysm (a swelling of the large artery in the abdomen) may be offered to older men and women with a family history of this condition or risk factor such as hypertension and smoking. Inquiry is sometimes made concerning symptoms of depression, and questions to detect any abuse or neglect by family or other caregivers may also be asked.