things we knew, things we did… things we have learnt, things we should do prevention:...
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Things we knew, things we did… Things we have learnt, things we should do
Prevention: consultations for the 50 years
old patient in general medicine
Docteur Guy RECORBETDocteur Guy RECORBETMarseilleMarseille
[email protected]@wanadoo.fr
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Summary
DefinitionsAround the WorldPrevention ConsultationPrevention Guidelines
• Eating Behavior• Screening• Addictive behavior• Suicide risks• High-risk sexual behavior
Questionnaire
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DEFINITIONS
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According to the WHO, health prevention includes all steps taken to avoid the onset, development of an illness or the occurrence of an accident.
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1.2 Primary prevention
The goal of a primary prevention is to avoid the onset of an illness by acting upon the causes.
This means acting on the risk factors of an illness before they occur, or preventing transmission or an infection (e.g. vaccinations).
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1.3 Secondary prevention
Secondary prevention aims to detect an illness or damage that precedes a stage where one can intervene.
The goal is to detect illnesses and to prevent the onset of clinical or biological symptoms (e.g. screening for breast cancer).
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1.4 Tertiary prevention
The objective of tertiary prevention is to reduce recidivism, incapacities and to support social re-integration
The goal is to limit the complications and sequelae of an illness.
It is generally carried out during or after treatment and attempts to limit the severity of the consequences of the disease (e.g. prevention of recurrent myocardial infarctions).
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1.5 In fact, non-specifics
In practice, the classification of a prevention action may vary according to different criteria, the population affected by this action, its aim, as well as the associated pathology.
Therefore, helping someone to quit smoking is a primary prevention when it affects teenagers or young adults. It is a secondary prevention in people who don’t have any symptoms, but who are presenting precancerous alterations of sputum cells. Finally, it is a tertiary prevention in patients suffering from angina pectoris.
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1.6 Individual and Group Prevention
Individual prevention is aimed at a specific individual.
Group prevention is aimed at an entire population or a target group within a population.
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1.7 Individual and Group Prevention
These two notions are often interrelated. Hence, a physician can take part in a group prevention by providing information on mammograms within a breast cancer screening campaign, whereas he is participating in an individual prevention if he prescribes a mammogram outside of an organized framework.
Finally, health education is aimed at the comprehension and control of an illness and its treatment by the patient, but it also broadly includes behavior and lifestyle.
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Around the World
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2.1 Prevention around the World
United Kingdom, Finland, Quebec...• The General Practitioner has a central role in prevention
policies.
• Absence of Prevention Consultation• Other forms of remuneration, principle of delegating tasks
and competences.• Experienced PCs in Quebec and Belgium (CVRF++)
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2.2 Prevention around the World
In France
A specific prevention consultation does not exist, except in an experimental framework or in pilot studies.
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2.3 Prevention around the World
In DenmarkOne "general consultation to promote good health" per
year.Remuneration identical to a consultationContested by general practitionersLittle impact on prevention policy
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2.4 Prevention around the World
In GermanyIncreased public awareness of physicians by IMF and
CMECreation of a new occupational titleHighlighting the preventative aspect of medicine
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2.5 Prevention around the World
In NorwayRemuneration of physicians by capitation with
bonuses for preventative actions(e.g.: smoking consultation)
In SwedenAbandonment of capitationSignificant role of other professionals
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2.6 Prevention around the World
In ItalyEssential role for GPs in local health agenciesRemuneration by capitation with compensation for
prevention programs
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Prevention Consultation
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3.1 Why a prevention consultation?
Prevention in GM = 1/3 of the reasons for consultation *CVR, cancer and vaccinations ++
But, random and not well structured
Included case by case in health-care activities
Preventative care and curative care are not clearly individualized (difficulties with identification)
Underevaluation of acts linked to prevention in GM
* FSGM
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3.2 Goals of a prevention consultation
Create a favorable moment specifically dedicated to prevention
Early detection of risks and illnesses
Structured and hierarchical implementation of interventions (related to prevention) based on professional recommendations
Develop a synergy between individual and group prevention
Initiate a process of health education (accountability of patients)
Participate in the assessment of practices and results
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3.3 Implementation principles for a prevention consultation
Methodology for analysis and management of individual risks according to Professor Ménard*:
Be informed about the most common diseases in the age group considered (incidence up to ten years)
Prioritize the most common diseases that may arise in the next decade and indentify the principal determinants of these illnesses
* Ménard Report 2005
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3.4 Implementation principles for a prevention consultation
3) Select screening methods (sensitiviy, specificity) that have a predictive reference value appropriate for the targeted group
4) Have immediate access to validated regulations of care and treatment of risks and their causes
5) Have immediate access to references from administrative, social or health structures, or health care professionals eventually necessary for an efficient care and treatment
6) Make this approach attractive for everyone
* Ménard Report 2005
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3.5 Hierarchy of risks
Age, Sex, Region, Profession
Causes of mortalityat 10 years
Causes of mortalityat 10 years
Height, Weight
Behavioral risksBehavioral risks• SmokingSmoking• Alcohol consumptionAlcohol consumption• EatingEating• Physical exercisePhysical exercise
Biological risksBiological risks• CardiovascularCardiovascular• CancersCancers• DepressionDepression
Environmental risksEnvironmental risks• Infections (vaccinations)Infections (vaccinations)• Work, activitiesWork, activities
Familial risksFamilial risks• Family historyFamily history
Other sources?Other sources?Lifetime risk?Lifetime risk?
J. Ménard, J. Ménard, SPIM, Juin 2006SPIM, Juin 2006
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3.6 Why a prevention consultation for patients in their fifties?
Premature mortality in France among the highest in Europe (Unexpected death before the age of 65)*: • 1/5th of total mortality (110,000 deaths annually)• 1/3 of deaths in men, 16.5% of deaths in women
Time difference (years) between exposure to a health risk and the apparition of the illness
At the age of 50: 60% of the causes of premature mortality can be prevented
Cancers (40%) and cardiovascular disease (11.9%), besides traumas, accidents and poisonings
* Ménard Report 2005
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Prevention Guidelines
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4.1 Causes of premature mortality based on sex (Inserm 1997)
Bronchopulmonary tumorsIschemic heart diseaseURDT cancerCerebrovascular diseasesAlcoholic cirrhosisColorectal cancerSuicideHeart failureCOPDProstate cancer
Breast cancerCerebrovascular diseaseIschemic heart diseaseColorectal cancerBronchopulmonary tumorsAlcoholic cirrhosisOvarian cancerSuicideUterine cancerHeart failure
Men Women
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4.2 Prevention Guidelines
Eating BehaviorPhysical ActivitiesOrganized screeningAddictive BehaviorSuicide RiskHigh-Risk Sexual Behavior
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4.2.1 Eating Behavior
• Too many calories overall Obesity• Excess of hidden fat (french fries, deli meat, cheese)• Excess of simple sugars (pastries, candy, sugary drinks)• Excess of salt• Certain deficiencies: iron, Mg, starch, fibers
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4.2.2 Eating Behavior Health Consequences
Accidents: no breakfast, alcohol, postprandial drowsinessCardiovascular diseases such as atherosclerosis or HT
(avoidable risk factor)Metabolic diseases: diabetes, obesityCertain cancers
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4.2.3 Eating Behavior SUVIMAX STUDY
(Antioxydant Vitamin and Mineral supplements)
13,000 volunteers during 8 yearsBeta carotene, Vitamin E, Selenium and Zinc
supplementsReduced mortality (-31%) and with all causes of
death combined (-37%)Eat 5 fruits and vegetables per day
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4.3.1 ALCOHOL AND RISKY BEHAVIOR
The WHO classification and the standard 10g "bistro" amountNormal consumption
• Less than 30 g/d or 210 g/week for men• Less than 20 g/d or 140 g/week for women
The at-risk drinkers: above these amounts but without physical, psychological or social repercussions
Excessive drinkers (= harmful use): non-specific signs of alcoholismDependencyAcute consumption
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4.3.2 REPORT (1)
Excessive drinkers: 5 to 6 million FrenchDependant on alcohol: 2 million45% of traffic accidents due to alcohol30% of fatalities75% of night-time mortalities!
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4.3.2 REPORT (2)
20% of work accidents 20% of hospitalized patients and patients who consult
a doctor have problems with alcohol20% of domestic accidents1 out of 4 suicides are alcohol-related40,000 to 50,000 deaths per year: 10% of all causes
of mortality combined
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4.3.4 ALCOHOL AND INDIVIDUAL PREVENTION
Screen the at-risk and excessive drinkersKeep track of the number of glasses of alcohol consumed
dailyRecognize the nonspecific symptoms and be aware of their
causesRapid screening tools: "CAGE" questionnaire (or "DETA", in
French)Clinical and biological signs
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4.3.5 STANDARDIZED CAGE - DETA QUESTIONNAIRE
Have you already felt the need to Reduce the amount of alcohol you drink?
Have your Friends and family commented on how much alcohol you drink?
Do you have the impression that you drink Too much?Have you ever needed to drink Alcohol in the morning in order to feel
like yourself?
Two or more positive answers indicate a possible alcohol problem
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4.4.1 SMOKING INDIVIDUAL AND GROUP PREVENTION
Consumption: "Anti-smoking" law37% of men and 31% of women smoke; 20% and 7%
of these men and women, respectively, smoke more than 20 cigarettes per day
Significance of smoking among youths: equality between the two sexes
In 1 year, reduction of comsumption by 18% (price increases)
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4.4.2 EFFECTS OF SMOKING ON HEALTH (1)
4 million deaths world-wide in 1998 (WHO) in one generation: 10 million deathsOne half of smokers die from a disease directly linked
to smoking
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4.4.3 EFFECTS OF SMOKING ON HEALTH (2)
More than half of the deaths are of an oncological nature (of which 21,000 are localized in the lungs)
The risk of lung cancer is multiplied by 2 when the amount of smoking is multiplied by 2
If the length of time is multiplied by 2, the risk is multiplied by 20
Upper respiratory and digestive tract cancers are multiplied by 150 if the patient smokes more than 30 cigarettes per day and drinks more than 120 g of alcohol per day
Bladder cancers: risk multiplied by 2
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4.4.4 EFFECTS OF SMOKING ON HEALTH (3)
One quarter of deaths: of a cardiovascular nature, the risk of ischemic heart disease is multiplied by 20 (infarctus and sudden death)
Smoking is a risk factor for CVA, arteritis, HT1/5 of these deaths are due to a respiratory system
disease: COPD, emphysema…3,000 annual deaths are attributed to passive smoking
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4.4.5 PASSIVE SMOKING
Lung cancer +26%Sinus cancer multiplied by 2 to 6 (not seen in the smoker
themselves)Heart diseases +25%Independent risk of CVA in spouses/partners (multiplied by
2 in a study)Passive smoking could be a source of decompensation in
patients with chronic respiratory diseases (COPD, asthma, etc.)
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4.4.6 EFFECTS OF SMOKING IN PREGNANT WOMEN
28% of pregnant women smoke3 times more spontaneous miscarriages2 times more ruptured membranes (stops during the course of the
1st trimester RR 1.6)Retardation of interuterine growth: multiplied by 2EP: RR at 1.5 if less than 10 cigarettes per day, RR at 3 if 20
cigarettes per day and at 5 if more than 30Risk of abruptio placentae and placenta previa increases
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4.4.7 AND FOR WOMEN?
Female deaths will be multiplied by 10 in 2025 if no steps are taken
1950: 20% of women and 60% of men were smoking2000: 31% of women and 37% of men... In 1995: 58.3% of women aged 18 to 24 were smoking
compared to 52% of menMortality due to lung cancer is higher than that of breast
cancer in three countries: CANADA, USA and DENMARK
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4.4.8 INDIVIDUAL SMOKING PREVENTION
The general practitioner is on the first lineShort-term intervention at each consultation: ask
about consumption and about stoppingArguments based on age groupsStopping: the methodsThe influence of physician behavior
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4.4.9 Assess the pharmacological dependence: FAGERSTROM TEST
How soon after waking up do you smoke your 1st cigarette?
• Within 5’ 3• Between 6' and 30' 2• Between 31' and 60' 1• At least 1h 0
Do you find it difficult not to smoke in places where it's forbidden?
• Yes 1• No 0
Which cigarette would be most difficult to skip?
• The first 1• Any other 0
How many cigarettes do you smoke each day?
• 10 or less 0• 11-20 1• 21-30 2• More than 30 3
Do you smoke more in the morning than in the afternoon?
• Yes 1• No 0
Do you smoke if you're sick or have to stay in bed?
• Yes 1• No 0
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4.4.10 NICOTINE DEPENDENCE
0-2 not dependent3-4 low dependence5-6 moderate dependence7-10 high, or very high, dependence
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4.5.1 Drugs and Medicine
Barbituates, Benzodiazepines, combined with alcoholAmphetamines, EcstasyCannabisCocaineHallucinogensOpiates
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4.5.2 Drugs and Medicine - Health Consequences
Psychiatric disordersAccidentsViral infections: HBV, HCV (80% of drug addicts are
infected) and HIV (30%)
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4.5.3 Drugs and Medicine - Health Consequences
The high-risk subject (predisposed personality, exposed environment- either within or outside of the family)
Occasional user of "soft" drugs, transition to drug addictSecondary prevention or risk reduction policy:
"substitution”, prevention of viral transmissions (syringes, "clean needles", risky sexual behavior)
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4.5.4 Drugs and Medicine Health Consequences
Community outreach activities (work) Legislative measuresTherapeutic injunctionLiberalization of the sale of syringes and their distributionPunishment of traffickers, campaigns against laundering drug
moneyWelcome center for drug addicts, liasion by a doctor, access to
care...
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4.6.1 Individual and Group Suicide Prevention
12,000 deaths per year
73% of men and 27% of women
3,000 among persons older than 65 (we don't talk about them often…)
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4.6.2 Evaluation Factors for Suicide Mortality Risk
Social factors – epidemiologicalAge: elderly subjects are most vulnerable, but it is one
cause of mortality among other causesSex: much higher risk in men than in womenIsolation: celibate men or period following a separationProfessional problems: precariousness and subjects who
lost a job a long time ago
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4.6.3 Evaluation Factors for Suicide Mortality Risk: Psychiatric Factors
Depression: unipolar or bipolar, with major anxiety or during the introduction of a disinhibitory drug. Mortality rate: 15%
Factors favoring the short-term: severe anxiety, loss of concentration and alcohol abuse
Factors favoring the long-term: previous suicide attempts, thoughts of suicide and despair
SchizophreniaPersonality disorders: increased risk in cases of alcoholism or
drug addiction, and during a psychiatric hospitalization
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4.6.4 Suicidal Behavior
20 to 50% of suicidals try again1% will succeed in the year following an attemptHigh prevalence of psychiatric disorders among
suicidals: 90%, of which 50% were depressed and 30% were alcoholics
The screening scales are deceiving (serenity before the act)
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4.6.5 Prevention of Suicide
Recognition of risk of suicide with an implementation of a psychotherapeutic and chemotherapeutic approach
Recognition of depression in older subjects (look for cognitive disorders)
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4.6.6 Screen for the Risk of Suicide
Take note of a history of suicide risk in adolescence: include this question during normal consultations.
It is useful to know about past attempts because the risk of death is strongly correlated to the existence of attempts.
Experience shows that talking about it does not provoke one to act upon it
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4.7.1 High-Risk Sexual Behavior
Prevent sexually transmitted infections by changing behavior.
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The Organization of a Prevention Consultation
Interrogate• Starting with a validated questionnaire
Examine• Be systematic
Educate• Starting with identified risks
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Putting the brakes on a Prevention Consultation
Patient resistance (40.1%) Not enough time (29.7%), Not enough training (7.1%), Lack of remuneration (6.7%)An impression of inefficacy (2.9%)Not valuable (1%).
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Prevention for patients in their Fifties
Questionnaire
Dr. Guy RECORBETMARSEILLE
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1- Identification
SexAgeHeightWeightBPHeart Rate
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2- Family History
(Grandparents, Parents, Brothers, Sisters...)?
Early Cardiovascular Diseases (Stroke, Embolism, Hypertension, Infarctus ...) men < 55 years, women < 65 years?
Colon, lung, prostate, ovarian, breast, uterine cancer? Diabetes?Hypercholesterolemia?
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3 – General Order
Do you smoke? If yes, do you want to quit?Do you regularly drink alcoholic beverages (beer, wine,
whiskey...)Have you already been treated for heart or artery
disease?Have you already been treated for cancer?Are your sugar levels too high (Diabetes)?Is your cholesterol level too high ( Hyperlipidemia)?Have you already had suicidal thoughts?
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4 – Linked to Sex
If you are a woman
Last pap smear?Last mammogram?
If you are a manLast PSA (Prostate)?
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5 – In all Cases
Last Hemoccult (testing stool for blood)? Last blood work-up?Last vaccination against tetanus?Last flu vaccination?
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6 – Last known analysis
Cholesterol?
Glycemia (sugar)?
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7 - Treatment
For cholesterol?For diabetes?For stress?For the heart?
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Do you want to go deeper into other issues with your doctor?
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Conclusion
PC fits within a strengthened prevention policy
Objective: fight against high premature mortality
Conditions • Must not be an isolated or exceptional act• Must be integrated within a global process of promoting health
(customized prevention plan and therapeutic education)• Must be organized and structured (hierarchization and analysis of
principal individual risks) • Training and interest of professionals• Must be evaluated (avoid the juxtaposition of instruments)
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Thank you for your Attention