Update on age-appropriate preventive measures and screening for Canadian primary care providers

Tawnya Shimizu; Manon Bouchard; Cleo Mavriplis

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Figure 1.
Sample charting tool for age-appropriate primary prevention maneuvers for women aged 21 to 49 y*: Recommendations with good evidence are presented in boldface; those with fair evidence are presented in italic text; consensus recommendations are presented in plain text. These recommendations are intended for primary care prevention and screening. Additional testing or physical examination, as required, for pre-existing conditions and presenting complaints might be warranted.
BMI—body mass index; BP—blood pressure; FINDRISC—Finnish Diabetes Risk Score; HbA_1c—hemoglobin A_1c; HBV—hepatitis B virus; HPV—human papillomavirus; HT—height; MMR—measles-mumps-rubella; STI—sexually transmitted infection; Td—tetanus and diphtheria; Tdap—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; VDRL—Venereal Disease Research Laboratory; WC—waist circumference; WT—weight.
^*Additional templates for other age and sex categories are available from CFPlus.

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Table 1.

The 2015 Primrose Preventive Screening Guidelines: Recommendations with good evidence are presented in boldface; those with fair evidence are presented in italic text; consensus recommendations are presented in plain text. These recommendations are intended for primary care prevention and screening. Additional testing or physical examination, as required, for pre-existing conditions and presenting complaints might be warranted.

MANEUVER	RECOMMENDATIONS

	AGE 21–49 Y	AGE 50–64 Y	AGE ≥ 65 Y
History and counseling
• Substances	Smoking¹⁴ Alcohol^15,16: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances¹⁷	Smoking Alcohol: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances	Smoking Alcohol: ≤ 10 drinks/wk for women, ≤ 15 drinks/wk for men Other substances
• Physical activity	150 min/wk moderate or vigorous intensity¹⁸ (cannot say more than a few words without pausing for breath)	150 min/wk moderate or vigorous intensity (cannot say more than a few words without pausing for breath)	150 min/wk moderate or vigorous intensity (cannot say more than a few words without pausing for breath)
• Diet and nutrition	Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt¹⁹	Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt	Fruit, vegetables, whole grains, healthy fat, ≤ 2000 mg/d of salt
• Sun exposure	Protective clothing, sunscreen²⁰	Protective clothing, sunscreen	Protective clothing, sunscreen
• Sexual activity	Safe sex and STI counseling²¹ (Screen for chlamydia and gonorrhea annually until age 25 y if sexually active and beyond age 25 y if high risk)	Safe sex and STI counseling if high risk	Safe sex and STI counseling if high risk
• Advance directives			Discuss once²²
• Supplements	Vitamin D: 400–2000 IU/d²³ Calcium: 1000 mg/d from diet²⁴; 1500–2000 mg/d if pregnant or lactating²⁵	Vitamin D: 1000–2000 IU/d Calcium: 1200 mg/d mainly from diet	Vitamin D: 1000–2000 IU/d Calcium: 1200 mg/d mainly from diet
• Physical examination^*	BP,²⁶ height, weight, BMI,²⁷ WC²⁸ If obese (30 kg/m² ≤ BMI < 40 kg/m²) offer or refer to structured behavioural interventions aimed at weight loss	BP, height, weight, BMI, WC If obese (30 kg/m² ≤ BMI < 40 kg/m²) offer or refer to structured behavioural interventions aimed at weight loss	BP, height, weight, BMI, WC If obese (30 kg/m² ≤ BMI < 40 kg/m²) offer or refer to structured behavioural interventions aimed at weight loss
Investigations and screening tests
• Cognitive			Screen if a family member is concerned²⁹; memory complaints should be evaluated and followed to assess progression
• Falls			Ask about trips or falls in past year or fear of falling³⁰
• STI	Gonorrhea and chlamydia³¹ VDRL, HIV, and HBV if high risk	Gonorrhea and chlamydia VDRL, HIV, and HBV if high risk	Gonorrhea and chlamydia VDRL, HIV, and HBV if high risk
• Diabetes^†	Assess HbA_1c level if FINDRISC score > 14³²	Assess HbA_1c level if FINDRISC score > 14	Assess HbA_1c level if FINDRISC score > 14
• Lipid levels^‡	Risk assessment³² Screen men ≥ 40 y	Risk assessment Screen women ≥ 50 y or menopausal	Risk assessment
• Vision	19–40 y every 10 y³³; 41–49 y every 5 y unless high risk (African American, high myopia, diabetes, or hypertension)	50–55 y every 5 y; 56–64 y every 3 y unless high risk (African American, high myopia, diabetes, or hypertension)	Annually
• Colon cancer		FIT or FOBT every 2 y or flexible sigmoidoscopy every 10 y³⁴	FIT or FOBT every 2 y or flexible sigmoidoscopy every 10 y until 75 y
• Osteoporosis		Screen based on risk factors	Screen women and men once > 65 y³⁵
• Immunizations^§	Td, Tdap, HPV, MMR Pneumococcal, influenza, varicella, polio, meningococcal conjugate^36–38	Td, Tdap, pneumococcal influenza, herpes zoster, varicella, polio	Td, Tdap, pneumococcal, influenza, herpes zoster, varicella, polio
Women
• Family planning	Folic acid: 0.4–1 mg/d at childbearing age³⁹ Rubella serology⁴⁰
• Cervical cancer	Start at age 25 y if sexually active,^‖ every 3 y if results are normal⁴¹	Every 3 y if results are normal	Every 3 y if results are normal; stop at age 69 y if 3 normal results in past 10 y
• Breast cancer		Mammogram every 2 y⁴²	Mammogram every 2 y; stop at age 75 y
Men
• AAA screen			Abdominal ultrasound once at age 65–75 y in patients who have ever smoked⁴³

AAA—abdominal aortic aneurysm; BMI—body mass index; BP—blood pressure; CVD—cardiovascular disease; FINDRISC—Finnish Diabetes Risk Score; FIT— fecal immunochemical test; FOBT—fecal occult blood test; HbA_1c—hemoglobin A_1c; HBV—hepatitis B virus; HPV—human papillomavirus; MMR—measles-mumps-rubella; STI—sexually transmitted infection; Td—tetanus and diphtheria; Tdap—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; VDRL—Venereal Disease Research Laboratory; WC—waist circumference.
WC measurements should be as follows:
- < 94 cm in men and < 80 cm in women of European, sub-Saharan African, Eastern Mediterranean, or Middle Eastern (Arab) descent;
- < 90 cm in men and < 80 cm in women of South Asian, Japanese, or Chinese descent; and
- <102 cm in men and < 88 cm in women are currently used for all other backgrounds for clinical purposes, but prevalence should be given using both European and North American cutoff points to allow better comparisons in future epidemiologic studies of populations of Europid descent.
From late middle age until ≥ 80 y there is a decline in the volume of subcutaneous fat and a redistribution of fat from subcutaneous to visceral depots. This might make WC risk factors less valid in older patients.
FINDRISC rates diabetes risk within the next 10 y:
- 0–14 points = low to moderate risk (1%–17% chance of developing diabetes within 10 y); recommend not screening for type 2 diabetes.
- 15–20 points = high risk (33% chance of developing diabetes within 10 y); recommend screening every 3–5 y with assessment of HbA_1c.
- ≥ 21 points = very high risk (50% chance of developing diabetes within 10 y); recommend annual screening with assessment of HbA_1c.
Risk assessment: use the Framingham score (multiplied by 2 if there is a family history) or use a cardiovascular age calculator (www.cvage.ca).
- If the Framingham risk score is < 5%, screen every 3–5 y; ≥ 5% repeat screening annually.
- Screen men ≥ 40 y and women ≥ 50 y or postmenopausal (consider earlier in ethnic groups at increased risk such as South Asian or First Nations patients) or all patients with any of the following, regardless of age: current smoker, diabetes, arterial hypertension, family history of premature CVD, family history of hyperlipidemia, erectile dysfunction, chronic kidney disease, inflammatory disease, HIV, chronic obstructive pulmonary disease, clinical evidence of atherosclerosis or abdominal aneurysm, clinical manifestation of hyperlipidemia, or obesity (BMI > 27 kg/m²).
- Framingham risk score only validated to age 74 y.
The following are the routine adult immunizations for individuals with low risk.
- Td: primary series for previously unimmunized adults; booster dose every 10 y.
- Pertussis: 1 dose of acellular pertussis–containing vaccine (Tdap) in adulthood; adults who will be in close contact with infants should be immunized as early as possible.
- HPV: bivalent (HPV2) or quadrivalent (HPV4) vaccine for women ≤ 26 y; HPV4 vaccine for men ≤ 26 y. Can be given at > 27 y if high risk of exposure.
- Measles and mumps: 1 dose for susceptible adults born in or after 1970; consider patients born before 1970 to be immune.
- Rubella: 2 doses for travelers, postsecondary students, military personnel, and health care workers; if vaccine is indicated, pregnant women should be immunized after delivery.
- Herpes zoster: 1 dose in those ≥ 60 y; those 50–59 years of age can be given 1 dose, but immunity wanes after 5 y.
- Influenza: encouraged for adults; recommended for those ≥ 65 y.
- Pneumococcal 23-valent polysaccharide: 1 dose for those ≥ 65 y.
- Polio: primary series for previously unimmunized adults when a primary series of tetanus and diphtheria toxoid–containing vaccine is being given or with routine tetanus and diphtheria toxoid–containing vaccine booster doses.
- Varicella: 2 doses in susceptible adults ≤ 49 y; if patients previously received 1 dose they should receive a second dose; 2 doses in adults ≥ 50 y who are known to be seronegative.
- Meningococcal conjugate: 1 dose in adults ≤ 24 y not immunized in adolescence.
↵‖ Sexual activity includes intercourse and digital or oral sexual activity involving the genital area with a partner of either sex.