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Prevention: consultations for the 50 years old patient in general medicine

Prevention: consultations for the 50 years old patient in general medicine. Docteur Guy RECORBET Marseille guy.recorbet@wanadoo.fr. Definitions Around the World Prevention Consultation Prevention Guidelines Eating Behavior Screening Addictive behavior Suicide risks

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Prevention: consultations for the 50 years old patient in general medicine

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  1. Prevention: consultations for the 50 years old patient in general medicine Docteur Guy RECORBET Marseille guy.recorbet@wanadoo.fr

  2. Definitions Around the World Prevention Consultation Prevention Guidelines Eating Behavior Screening Addictive behavior Suicide risks High-risk sexual behavior Questionnaire Summary

  3. DEFINITIONS

  4. According to the WHO, health prevention includes all steps taken to avoid the onset, development of an illness or the occurrence of an accident.

  5. 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). 1.2 Primary prevention

  6. 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). 1.3 Secondary prevention

  7. 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). 1.4 Tertiary prevention

  8. 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. 1.5 In fact, non-specifics

  9. Individual prevention is aimed at a specific individual. Group prevention is aimed at an entire population or a target group within a population. 1.6 Individual and Group Prevention

  10. 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. 1.7 Individual and Group Prevention

  11. Around the World

  12. 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++) 2.1 Prevention around the World

  13. In France A specific prevention consultation does not exist, except in an experimental framework or in pilot studies. 2.2 Prevention around the World

  14. In Denmark One "general consultation to promote good health" per year. Remuneration identical to a consultation Contested by general practitioners Little impact on prevention policy 2.3 Prevention around the World

  15. In Germany Increased public awareness of physicians by IMF and CME Creation of a new occupational title Highlighting the preventative aspect of medicine 2.4 Prevention around the World

  16. In Norway Remuneration of physicians by capitation with bonuses for preventative actions (e.g.: smoking consultation) In Sweden Abandonment of capitation Significant role of other professionals 2.5 Prevention around the World

  17. In Italy Essential role for GPs in local health agencies Remuneration by capitation with compensation for prevention programs 2.6 Prevention around the World

  18. Prevention Consultation

  19. 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 3.1 Whya prevention consultation? * FSGM

  20. 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 3.2 Goals of a prevention consultation

  21. 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 3.3 Implementation principles for a prevention consultation * Ménard Report 2005

  22. 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 3.4 Implementation principles for a prevention consultation * Ménard Report 2005

  23. 3.5 Hierarchy of risks Age, Sex, Region, Profession Causes of mortality at 10 years Other sources? Lifetime risk? Height, Weight • Behavioral risks • Smoking • Alcohol consumption • Eating • Physical exercise • Biological risks • Cardiovascular • Cancers • Depression • Environmental risks • Infections (vaccinations) • Work, activities • Familial risks • Family history J. Ménard, SPIM, Juin 2006

  24. 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 3.6 Why a prevention consultation for patients in their fifties? * Ménard Report 2005

  25. Prevention Guidelines

  26. Bronchopulmonary tumors Ischemic heart disease URDT cancer Cerebrovascular diseases Alcoholic cirrhosis Colorectal cancer Suicide Heart failure COPD Prostate cancer Breast cancer Cerebrovascular disease Ischemic heart disease Colorectal cancer Bronchopulmonary tumors Alcoholic cirrhosis Ovarian cancer Suicide Uterine cancer Heart failure 4.1 Causes of premature mortality based on sex (Inserm 1997) Men Women

  27. Eating Behavior Physical Activities Organized screening Addictive Behavior Suicide Risk High-Risk Sexual Behavior 4.2 Prevention Guidelines

  28. 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 4.2.1 Eating Behavior

  29. Accidents: no breakfast, alcohol, postprandial drowsiness Cardiovascular diseases such as atherosclerosis or HT (avoidable risk factor) Metabolic diseases: diabetes, obesity Certain cancers 4.2.2 Eating Behavior Health Consequences

  30. 13,000 volunteers during 8 years Beta carotene, Vitamin E, Selenium and Zinc supplements Reduced mortality (-31%) and with all causes of death combined (-37%) Eat 5 fruits and vegetables per day 4.2.3 Eating Behavior SUVIMAX STUDY (Antioxydant Vitamin and Mineral supplements)

  31. The WHO classification and the standard 10g "bistro" amount Normal 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 alcoholism Dependency Acute consumption 4.3.1 ALCOHOL AND RISKY BEHAVIOR

  32. Excessive drinkers: 5 to 6 million French Dependant on alcohol: 2 million 45% of traffic accidents due to alcohol 30% of fatalities 75% of night-time mortalities! 4.3.2 REPORT (1)

  33. 20% of work accidents 20% of hospitalized patients and patients who consult a doctor have problems with alcohol 20% of domestic accidents 1 out of 4 suicides are alcohol-related 40,000 to 50,000 deaths per year: 10% of all causes of mortality combined 4.3.2 REPORT (2)

  34. Screen the at-risk and excessive drinkers Keep track of the number of glasses of alcohol consumed daily Recognize the nonspecific symptoms and be aware of their causes Rapid screening tools: "CAGE" questionnaire (or "DETA", in French) Clinical and biological signs 4.3.4 ALCOHOL AND INDIVIDUAL PREVENTION

  35. 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 4.3.5 STANDARDIZED CAGE - DETA QUESTIONNAIRE

  36. Consumption: "Anti-smoking" law 37% 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) 4.4.1 SMOKING INDIVIDUAL AND GROUP PREVENTION

  37. 4 million deaths world-wide in 1998 (WHO) in one generation: 10 million deaths One half of smokers die from a disease directly linked to smoking 4.4.2 EFFECTS OF SMOKING ON HEALTH (1)

  38. 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 4.4.3 EFFECTS OF SMOKING ON HEALTH (2)

  39. 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, HT 1/5 of these deaths are due to a respiratory system disease: COPD, emphysema… 3,000 annual deaths are attributed to passive smoking 4.4.4 EFFECTS OF SMOKING ON HEALTH (3)

  40. 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.) 4.4.5 PASSIVE SMOKING

  41. 28% of pregnant women smoke 3 times more spontaneous miscarriages 2 times more ruptured membranes (stops during the course of the 1st trimester  RR 1.6) Retardation of interuterine growth: multiplied by 2 EP: 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 30 Risk of abruptio placentae and placenta previa increases 4.4.6 EFFECTS OF SMOKING IN PREGNANT WOMEN

  42. Female deaths will be multiplied by 10 in 2025 if no steps are taken 1950: 20% of women and 60% of men were smoking 2000: 31% of women and 37% of men... In 1995: 58.3% of women aged 18 to 24 were smoking compared to 52% of men Mortality due to lung cancer is higher than that of breast cancer in three countries: CANADA, USA and DENMARK 4.4.7 AND FOR WOMEN?

  43. The general practitioner is on the first line Short-term intervention at each consultation: ask about consumption and about stopping Arguments based on age groups Stopping: the methods The influence of physician behavior 4.4.8 INDIVIDUAL SMOKING PREVENTION

  44. 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 4.4.9 Assess the pharmacological dependence: FAGERSTROM TEST

  45. 0-2 not dependent 3-4 low dependence 5-6 moderate dependence 7-10 high, or very high, dependence 4.4.10 NICOTINE DEPENDENCE

  46. Barbituates, Benzodiazepines, combined with alcohol Amphetamines, Ecstasy Cannabis Cocaine Hallucinogens Opiates 4.5.1 Drugs and Medicine

  47. Psychiatric disorders Accidents Viral infections: HBV, HCV (80% of drug addicts are infected) and HIV (30%) 4.5.2 Drugs and Medicine - Health Consequences

  48. The high-risk subject (predisposed personality, exposed environment- either within or outside of the family) Occasional user of "soft" drugs, transition to drug addict Secondary prevention or risk reduction policy: "substitution”, prevention of viral transmissions (syringes, "clean needles", risky sexual behavior) 4.5.3 Drugs and Medicine - Health Consequences

  49. Community outreach activities (work) Legislative measures Therapeutic injunction Liberalization of the sale of syringes and their distribution Punishment of traffickers, campaigns against laundering drug money Welcome center for drug addicts, liasion by a doctor, access to care... 4.5.4 Drugs and Medicine Health Consequences

  50. 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…) 4.6.1Individual and Group Suicide Prevention

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