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 RECORBET

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

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 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).

6 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).

7 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).

8 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.

9 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.

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.

11 Around the World

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++)

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

Prevention around the World 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

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

Prevention around the World 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

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

18 Prevention Consultation

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

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

Implementation principles for a prevention consultation Methodology for analysis and management of individual risks according to Professor M é nard*: 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

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

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

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

25 Prevention Guidelines

Causes of premature mortality based on sex (Inserm 1997) 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 MenWomen

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

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

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

Eating Behavior SUVIMAX STUDY (Antioxydant Vitamin and Mineral supplements) 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

ALCOHOL AND RISKY BEHAVIOR 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

REPORT (1) 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!

REPORT (2) 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

ALCOHOL AND INDIVIDUAL PREVENTION 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

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

SMOKING INDIVIDUAL AND GROUP PREVENTION 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)

EFFECTS OF SMOKING ON HEALTH (1) 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

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

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, HT 1/5 of these deaths are due to a respiratory system disease: COPD, emphysema… 3,000 annual deaths are attributed to passive smoking

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.)

EFFECTS OF SMOKING IN PREGNANT WOMEN 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

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 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

INDIVIDUAL SMOKING PREVENTION 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

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 1h0 Do you find it difficult not to smoke in places where it's forbidden? Yes1 No0 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 More than 303 Do you smoke more in the morning than in the afternoon? Yes1 No0 Do you smoke if you're sick or have to stay in bed? Yes1 No0

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

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

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

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 addict Secondary prevention or risk reduction policy: "substitution”, prevention of viral transmissions (syringes, "clean needles", risky sexual behavior)

Drugs and Medicine Health Consequences 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...

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…)

Evaluation Factors for Suicide Mortality Risk Social factors – epidemiological Age: elderly subjects are most vulnerable, but it is one cause of mortality among other causes Sex: much higher risk in men than in women Isolation: celibate men or period following a separation Professional problems: precariousness and subjects who lost a job a long time ago

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 Schizophrenia Personality disorders: increased risk in cases of alcoholism or drug addiction, and during a psychiatric hospitalization

Suicidal Behavior 20 to 50% of suicidals try again 1% will succeed in the year following an attempt High 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)

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)

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

High-Risk Sexual Behavior Prevent sexually transmitted infections by changing behavior.

57 The Organization of a Prevention Consultation Interrogate Starting with a validated questionnaire Examine Be systematic Educate Starting with identified risks

58 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%).

59 Prevention for patients in their Fifties Questionnaire Dr. Guy RECORBET MARSEILLE

60 1- Identification Sex Age Height Weight BP Heart Rate

61 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?

62 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?

63 4 – Linked to Sex If you are a woman Last pap smear? Last mammogram? If you are a man Last PSA (Prostate)?

64 5 – In all Cases Last Hemoccult (testing stool for blood)? Last blood work-up? Last vaccination against tetanus? Last flu vaccination?

65 6 – Last known analysis Cholesterol? Glycemia (sugar)?

Treatment For cholesterol? For diabetes? For stress? For the heart?

67 Do you want to go deeper into other issues with your doctor?

68 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)

69 Thank you for your Attention