British Geriatrics Society

1. Executive Summary

Health checks are popular with the public, and older people are no exception, but their value is uncertain. Where healthcare is ageist, widespread unmet health needs in older people may exist. However, in the UK most people today will consult their General Practitioner regularly and be given health advice and a blood pressure check, with the potential to identify early disease. Annual checks by a nurse visit have been well evaluated, and have shown benefit in mortality outside the UK, but not in the UK. The benefits are maximised where a nurse is managing a small caseload with regular visits. Casefinding seeks to target proactive care on individuals likely to have high-level needs based on information held about them within IT systems. Individuals appreciate the resulting case management, but the potential for this to reduce mortality or hospital admissions has not been shown. When an older person has a crisis or experiences disability, a thorough assessment is needed; otherwise, individuals should be encouraged to follow healthy ageing advice.

2. Introduction

The history of casefinding probably has its origin in the work of Professor James Williamson¹ who published his findings from Edinburgh in 1964 and reported icebergs of undiagnosed problems and unmet needs in 200 people over 65 years of age. This was a wake-up call to the needs of older people, and the realisation that many will not seek medical advice, through ignorance that treatment may be possible or fear of medicalisation or institutionalisation. A series of studies in the 1970’s explored this further (eg Williams 1972² ) with a growing assumption that regular checks were essential to identify treatable health needs.  However, an early cautionary word was spoken by Ebrahim³ who showed that non-consulters generally had low levels of need. Randomised controlled trials from the UK in the 1980’s (Carpenter⁴ , Pathy⁵ , Vetter⁶ , McEwan⁷ ) were inconclusive regarding the benefits of health checks, yet the 1990 GP contract in the UK directed GP’s to invite all patients over 75 years to an annual health check with a review of “sensory functions, mobility, mental condition, physical condition, social environment, and use of medicines”.

This brief paper reviews the policy regarding health checks as a vehicle for prevention in old age.

3. Definitions / Terminology

Primary prevention is undertaken in the whole population with the aim of reducing the incidence of disease – examples are immunisation and keeping warm. Secondary prevention is the early detection of a disease enabling treatment and a reduction in impact – this therefore includes the concept of screening for existing yet asymptomatic disease. Tertiary prevention is an intervention on known disease to alter its course and minimise further complications or resulting disability and handicap. The usefulness of these distinctions may be diminished in the context of longterm conditions which evolve through risk factors whose management can influence all 3 levels. Nevertheless, the focus here is on secondary prevention and screening, and the benefits of doctor-initiated assessment of the whole population age group – a concept perhaps most familiar from mammography screening to detect early breast cancer. In older people, screening can also include tertiary prevention: looking for disability which has not yet been recognised and diagnosed.

4. Health Policy

In times when healthcare costs are soaring, there is a constant cry for prevention as the only real solution. The benefits of screening all older people for occult disease may at first sight seem obvious: this is a population with high prevalence of disease and a huge cost burden on health and social care. Older people often present to the hospital with an array of diseases that appear to be quite unknown and yet advanced, and it seems extraordinary that medical action has not been taken earlier. Many of the presenting conditions are slowly progressive, which surely would have been amenable to earlier effective management.

It is important to remember the criteria for effective screening:

1. The condition is common and of significant impact in terms of morbidity and/or mortality- this is certainly the case regarding subclinical disease in old age.
2. There is an accurate screening test with low false positives and low false negatives
3. The screening test is safe
4. The condition is amenable to effective intervention especially when detected early.
5. There is overall cost benefit.

The drawbacks are also considerable: screening converts happy ignorance into worried patients, which may lead to altered quality of life, or reduced autonomy – the belief that you are healthy has a strong positive influence on vitality and mortality; the potential to alter the course of many of the longterm conditions is quite limited; there are risks from investigations and preventive care measures; there are considerable costs involved in whole population screening, and these costs may be better directed at those already suffering and in greatest need.

5. Models of Service Provision

Single assessment and management
The simplest model of service provision is to visit all older people using comprehensive geriatric assessment principles, supplemented with blood tests, and then to investigate and manage each of the problems identified. The largest UK trial⁸ using this approach was published in 2004 involving over 33,000 patients, and randomised 106 general practices to either a universal approach - an in-depth nurse assessment with triggered referrals offered to all patients aged 75 or over, or a targeted approach – assessment of those who indicated 3 or more problems on a postal screen questionnaire. 90% of the universal subjects and 8% of the targeted subjects had the full assessment. Mortality, hospital admissions and care home admissions showed no difference between the groups, while there were very small changes in quality of life.

Annual or more frequent regular assessments
This model is based on the assumption that preventive visits are most likely to be of value if a relationship is built up over time to implement changes in lifestyle and management.  This has been studied in Holland⁹ and Denmark¹⁰, where the intervention group were visited 4 times a year for 3 years providing health advice and information, but no examination or blood tests. In Holland, no differences between control and intervention were seen for mortality or disability, but the intervention group were using more community care services with no change in care home admissions. In Denmark, use of hospital was reduced from 52% to 48%, use of care homes reduced from 29% to 20%, and mortality was slightly reduced. Each community nurse had a caseload of 95 older people.

Postal questionnaires to identify problems and disability
This model was used to focus on those with disability rather than searching for asymptomatic conditions. An annual postal health questionnaire is sent, and subjects with disability (Pathy⁵) or increasing disability (Carpenter⁴) were targeted for nurse assessments. Mortality was reduced in one study⁵ and care home admissions reduced in the other⁴, but neither showed differences in disability. There is some evidence from outside the UK that visits targeted at the most disadvantaged may be of benefit (Garcia-Pena ; Van Rossum⁹).

Systematic reviews
Two  reviews in 2000 and 2001 reached different conclusions. Haastregt¹² included 15 trials, and did not pool results because of heterogeniety: 8 trials reported at least one positive benefit – 3 with reduced mortality, 2 reduced care home admissions, and 5 improved disability. Elkan¹³ included 8 trials of whole population screening, 5 of which were included in the earlier study, and meta-analysis showed a 24% reduction in  mortality, yet no effect on disability or hospital admission. How mortality was reduced was unknown.  The meta-analysis has not been repeated since the MRC study, which was 50 times larger than any other study.

Casefinding using predictive models
An alternative method to a postal screen for selecting those for comprehensive assessment and case management is to use data already available through primary and secondary health care IT systems. The simplest method is defined primarily on recurrent hospital admissions. This was evaluated in the Evercare project¹⁴ , where older people with two or more recent admissions were contacted by community matrons. Similar to other screening methodologies, the interventions were broadly appreciated with improvement in quality of life scores, but when compared with localities not using the model there was no evidence for reduced hospital use¹⁵ . The Kings Fund and DH have promoted the use of a more complex predictive model, PARR+¹⁶ , but this has not so far been subjected to controlled evaluation, although is used in a number of case management services in the UK. “Predictive models” are indeed able to predict adverse outcomes, but it has not yet been shown whether there are definable subgroups where those outcomes can be altered. One limiting factor is the high mortality of these individuals with repeated admissions¹⁷ .

Individual conditions
There is consensus regarding the benefit of screening older people for cardiovascular disease risk factors, and this is not considered further here.
Hypothermia: no clear benefit has been shown for improved heating (it gets turned off!), heating allowances, or education programmes. Myxoedema: screening 100 old people would find 6 subclinical hypothyroid, 1 of whom would progress to clinical disease. Vitamin deficiency: there are high prevalences of specific vitamin deficiencies, but their clinical importance is controversial in an otherwise healthy individual. Dementia: detecting subclinical dementia is not possible reliably at present, and is not recommended. Early identification of dementia is desirable, although a screening programme could cause considerable anxiety. Depression: depression often goes unnoticed; a screening questionnaire is over-sensitive with high false positives. Visual acuity: the MRC study included a specific evaluation of the benefit of screening for visual impairment on acuity 3 years later, and did not find improved visual outcomes .

6. Responsibilities / Role of the Geriatrician

It is important that the geriatrician understands and promotes the clear benefits of a healthy lifestyle for healthy ageing – these are discussed in companion articles to the present one. Equally important is understanding the principle of comprehensive geriatric assessment when an older person does present with a functional problem. Where local programmes of screening or casefinding exist, the geriatrician should encourage monitoring and audit with critical evaluation.

7. Training

Where community nurses or matrons are running programmes of screening or casefinding, the Evercare programme and other experiences have shown the importance of operational links to consultants. This can be fostered through involvement in their training programmes, particularly around the presentation and management of longterm conditions.

8. Recommendations

The conflicting evidence from published trials is confusing. The absence of strong evidence in support of screening or casefinding may not mean that it is not worthwhile. There are general principles which have emerged :

• Older patients presenting to health and social care generally have greater needs than those who are not presenting, and their non-specific functional presentation must not hide the underlying diagnoses. These patients require comprehensive geriatric assessment to understand fully the context of their presentation, and to enable a holistic plan with the best chance of improving health and wellbeing. Some have called this “opportunistic screening” and it is a fundamental principle of geriatric medicine.
• A single intensive screening of the general elderly population in the UK context probably does not yield benefits in terms of disability reduction or mortality.
• The impact of a programme depends critically on the quality of primary healthcare within that community: in most parts of the UK in 2010, it is much harder to demonstrate a positive impact from screening. However there may settings and population subgroups where screening could deliver greater health gain.
• Health checks are valued by most older people, especially where non-intrusive and ‘low-tech’; they should offer healthy lifestyle advice and information, and can lead to an improved sense of well-being.
• Screening programmes must pay great attention to effective delivery of healthcare rather than just the collection of information about health and social care needs.
• Screening programmes probably need to be intensive with small caseloads, and sustained over several years to deliver benefits.
• Cost-effectiveness of health checks and case-finding cannot be evaluated in the UK until an effective model has been found through a controlled trial.

References

1. Williamson J et al Old people at home: their unreported needs. Lancet 1964;i:1117-20
2. Williams I et al Sociomedical study of patients over 75 in general practice. BMJ 1972;2:445-8
3. Ebrahim S, Hedley R, Sheldon M. Low levels of ill health among elderly non-consulters in general practice. BMJ 1984;289:1273-6.
4. Carpenter GI, Demopoulos GR. Screening the elderly in the community: controlled trial of dependency surveillance using a questionnaire administered by volunteers. BMJ 1990;300:1253-6.
5. Pathy MSJ, Bayer A, Harding K, Dibble A. Randomised trial of case finding and surveillance of elderly people at home. Lancet 1992;340:890-3.
6. Vetter N, Jones DA, Victor CR. Effect of health visitors working with elderly patients in general practice: a randomised controlled trial. BMJ 1984;288:369-72.
7. McEwan RT et al. Screening elderly people in primary care: a randomised controlled trial. Br J Gen Pract 1990;40:94-7.
8. Fletcher AE, Price GM, Ng ESW et al. Population-based multidimensional assessment of older people in UK general practice: a cluster-randomised factorial trial. Lancet 2004;364:1667-77.
9. Van Rossum E et al. Effects of preventive Home visits to elderly people. BMJ 1993;307:27-32.
10. Hendriksen C, Lund E, Stromgard E. Consequences of assessment and intervention among elderly people: a three year randomised controlled trial. BMJ 1984;289:1522-4.
11. Garcia-Pena C et al. Pragmatic randomised trial of home visits by a nurse to elderly people with hypertension in Mexico. Int J Epidemiol 2001;30:1485-91.
12. Haastregt JCM et al Effects of preventive home visits to elderly people living in the community: systematic review. BMJ 2000;320:754-8.
13. Elkan R et al Effectiveness of home based support for odler people: systematic review and meta-analysis. BMJ 2001;323:719-24.
14. UnitedHealth Europe. Assessment of the Evercare programme in England 2003-2004. www.cat.csip.org.uk/_library/evercare%20final%20report.pdf
15. Gravelle H, Dusheiko M, Sheaff R Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ 2007;334:31-2.
16. Kings Fund 2007 www.kingsfund.org.uk/current_projects/predicting_and_reducing_readmission_to_hospital/
17. I P Donald.  Is Evercare too late? Age and Ageing 2005; 34:199
18. Smeeth L, Fletcher AE, Hanciles S et al. Screening older people for impaired vision in Primary care: cluster randomised trial. BMJ 2003;327:1468.