Family Practice Vol. 17, No. 4, 329-333
© Oxford University Press 2000
Effects of screening for disorders among the elderly: an intervention study in general practice
a Department of General Practice,
b Department of Medical Decision Making and
c Department of Metamedica, Leiden University Medical Centre, PO Box 2088, 2301 CB Leiden, The Netherlands.
Just Eekhof.
Eekhof JAH, De Bock GH, Schaapveld K and Springer MP. Effects of screening for disorders among the elderly: an intervention study in general practice. Family Practice 2000; 17: 329–333.
Received 14 May 1999; Revised 15 February 2000; Accepted 13 March 2000.
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Abstract |
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Background. Preventive assessment of prevalent disorders may be considered as an instrument to maintain independence in the elderly. However, the outcomes of studies on these types of screening differ considerably regarding their effects.
Objectives. The aim of the present study was to assess the effects of GPs' screening of the elderly on four highly prevalent disorders with possibilities for treatment: hearing and visual disorders, urinary incontinence and mobility disorders.
Methods. In an intervention study in 12 general practices, 1121 subjects aged 75 years and over were screened. Randomization was done by practice into an intervention group (576) and a control group (545). In the intervention group, all elderly patients were screened for the four disorders during the first year of the study. When the GP and patient agreed on intervention, usual care was provided by the GP. The patients in the control group were not screened in the first year. In the second year, all patients in both groups were screened for the four disorders.
Results. For none of the four disorders was a measurable effect of the screening at the population level found. In the first year, 1013 new disorders were found involving 479 of 576 people. The GPs considered information to be new in 293 cases. In 245 cases (out of 293), the GP discussed the new information with the patient. Of the 89 cases in which the patient agreed with an intervention, improvement was reported in 17 cases.
Conclusions. Implementing a standardized screening programme for four highly prevalent disorders for elderly people is not recommended. Preventive assessment of the elderly should be applied in ways other than by screening. Preventive care should pay attention to the individual needs of the elderly, should be started before the age of 75 years and should be offered in a flexible way.
Keywords. Elderly, general practice, screening.
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Introduction |
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Results of studies regarding the effectiveness of screening among the elderly are inconclusive. A meta-analysis of trials showed that screening programmes with control over medical recommendations and extended ambulatory follow-up were likely to be effective.1 Most of the effective trials were performed in a hospital setting. Only a few home-based trials performed in the USA have demonstrated beneficial effects.2,3 In studies in European countries with a health care system similar to the Dutch system, these effects were not found.4–9 No results are as yet available on the effects of screening elderly people at the population level on functional disorders in general practice. In The Netherlands, a GP has at least one contact per year with 90% of the people of 75 years and older (mean six contacts). A substantial number of these contacts take place in the homes of the elderly and, in general, the GP is well informed about personal and environmental factors. The intensive relationship of the Dutch GP with the elderly in his practice provides a good opportunity to offer elderly people a screening programme. Within the concept of the disablement process (as drafted by Jette and Verbrugge) in The Netherlands, the GP is probably the most eligible person to judge impairments and disabilities in relation to personal and environmental factors in the elderly.10
The aim of this study was to assess the effects of GPs' screening for four widespread disorders of old age with possibilities for treatment. On the basis of a literature review, hearing and visual disorders, urinary incontinence and mobility disorders were considered suitable for screening.11
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Methods |
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Design
The study was conducted in the practices of 12 GPs, randomized in six strata pairs of GPs, matched by town/ countryside, group/solo practice, age, sex and number of years practising as a GP. Randomization was done by practice to prevent contamination within practices. Only the first 160 patients were selected (in alphabetical order) in order to achieve a comparable workload for the 12 GPs. Those patients who, according to the GP, were (i) too ill, (ii) suffering from dementia or (iii) not able to participate for other reasons were excluded from the study. In the intervention group, all elderly patients were screened in the first year of the study. In the control group, no action was taken in the first year. In the second year, all elderly patients in both groups were screened. When the GP and the patient considered it necessary, an intervention was started. Interventions consisted of the usual care offered by the GPs for the respective disorders (e.g. earwax removal, referral to an ENT specialist). The main purpose of the study was to investigate the effects of screening for disorders among the elderly by demonstrating differences in disorder prevalence in the intervention and control group.
The sample size was based on an expected prevalence of 30% of the four disorders and on an absolute difference of 10% between the intervention and the control group with regard to the disorders, assuming there were no differences between GPs in both groups. For a standard design, 360 patients were needed in both groups, i.e. six practices in both groups. If we allow a standard deviation of 0.05 between GPs, ~60% more patients would have been needed for a design with randomization at doctor level.12,13
The Medical Ethics Committee of the Leiden University Medical Centre approved the design, demanding informed consent from all participants.
Patients
In the intervention group, 576 out of 732 patients on the GPs' lists (registers) were included in the first year of the study. Forty-three patients were not able to participate (exclusion) and 113 dropped out. In the second year of the study, 483 out of 576 patients were re-investigated. To avoid focusing on the care for the elderly of the GPs in the control group, the first contact was at the start of the second year when a sample of 738 patients was defined, of whom 545 were investigated (Table 1
). No statistically significant differences in age and sex were found between the patients in the intervention group and the control group.
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Assessments and definitions
The four disorders were assessed on disability level with validated self-reporting questions taken from the OECD questionnaire.14,15 The impairments caused by hearing, visual and mobility disorders were also assessed by validated diagnostic tests. Usual functioning was assessed (e.g. vision was measured with the glasses usually worn). The following definitions were used.
- (i) A hearing disorder was defined as (a) having difficulty following a conversation with one person or, when in a group, with three or more persons, and/or (b) a positive standardized whispered voice test (hearing loss >30 dB).16
- (ii) A visual disorder was defined as (a) having difficulty in recognizing a face at 4 m, and/or reading the normal letters in a newspaper, and/or (b) impaired vision with both eyes (Snellen chart <0.3), or not being able to read normal newspaper letters at 25 cm distance.
- (iii) Urinary incontinence was defined as having urine loss twice or more per month.17
- (iv) A mobility disorder was defined as (a) having difficulty with at least one of the following activities: carrying 5 kg for 10 m, bending and picking up an object, walking for 400 m, getting in and out of bed, (un)dressing or transferring on one level, and/or (b) a positive timed ‘Up and go’ mobility test.18
- (ii) A visual disorder was defined as (a) having difficulty in recognizing a face at 4 m, and/or reading the normal letters in a newspaper, and/or (b) impaired vision with both eyes (Snellen chart <0.3), or not being able to read normal newspaper letters at 25 cm distance.
Finally, the GPs were asked to record if the findings were new and if the findings had been discussed with the patient. This discussion and the resulting outcomes were also recorded.
Procedure
Before starting the study, all GPs were trained in performing the whispered voice test, the vision tests and the Up and go test by the same investigator (J.A.H.E.). During the first 9 months in both study years, the GPs investigated the elderly following a contact. In the last 3 months, the elderly who had had no contact with the GP were invited to be tested at home or in the surgery of their GP.
Analysis
A comparison was made on baseline characteristics (age, sex and housing) within groups (intervention group of the first and the second year, paired t-test) and between groups (second year intervention group and control group, unpaired t-test).
To assess if screening followed by intervention did indeed lead to a reduction in the prevalence of the four disorders, 95% confidence intervals (CIs) were calculated.19 In view of the large heterogeneity between GPs, prevalence of the disorders was estimated by the mean prevalence per GP, and the standard error was computed accordingly (degree of freedom is number of GPs –1). It was assumed that the difference within a stratum of a pair of GPs was of the same order as the difference between all GPs. Therefore, the results will not be presented per stratum but for the group of GPs in the intervention and the control group. Data for this study were analysed using SPSS for Windows 7.0.
In all cases, the nature of the intervention was noted. At the end of the second year, the outcomes of the interventions were registered. Improvement was defined as absence of the disorder (according to the previously formulated definition) in the second year.
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Results |
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When taking the four disorders together for the 576 elderly patients in the first year, 1013 disorders were found involving 479 people (83%). The six GPs of the intervention group considered information to be new in 293 cases, concerning 226 people (47%) (Table 2
). In 245 cases (of the 293), the GP decided to discuss the new information with the patient. In less than half the cases (110), the patient agreed with an intervention. Of these, 97 people also participated in the second year. For hearing and visual disorders, the patient agreed with an intervention in 89 of the cases. In 30 of the 89 cases, the GP performed the intervention himself, and 59 cases were offered a referral or a referral was considered. Of those 59 people, 36 indeed visited the ENT specialist or ophthalmologist. In 17 out of 89 cases that complied with an intervention, improvement was reported, whereas in four cases the condition worsened. As a result of screening for urinary incontinence, the six interventions concerned the distribution of diapers, as a result of which two people improved in the second year. As a result of screening for mobility disorders, two people received a walking aid which did not, however, lead to improvement. Overall, no statistically significant differences were found at the group level between the results of the first and the second year, or between the second year of the intervention group and the control group (Table 3).
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Discussion |
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Screening followed by intervention by the GP did not lead to a statistically significant improvement in the four disorders at the population level in the intervention group of the second year, compared with the intervention group in the first year and the control group. At the individual level, the results of the interventions were beneficial; 19% of all cases that complied with an intervention improved.
Of the 93 people who dropped out between the first and second year in the intervention group, more than half died (48), 10 became too ill to participate, four moved to a nursing home and six developed dementia. These reasons for dropping out are self-evident in a study involving an elderly population. Only 25 people dropped out for reasons not related to old age: 12 moved to another town, eight refused to participate and five lists got lost. The difference in drop-outs in the intervention group and the control group did not influence the outcomes of the study. In other studies, no considerable differences in health and well-being have been found between those screened and those who declined a health check.20
GPs were well able to detect the impairments and disabilities of the elderly. Of all patients on the filing list, 79% were reached, 83% of them had at least one disorder of which 47% were considered to be new by the GP. Only half the people with whom the GP discussed a newly found disorder complied with an offer for intervention. In the study of Brown, only 12% of the over-75s were reached; 44% had at least one problem and in 82% of them action was taken.21 Because of a higher rate of participation, our figures are probably more representative.
In our study, we did not check on underlying depression which may have been a possible factor in refusing an intervention. Nevertheless, depression is present pervasively in all decisions regarding elderly people. As it is part of the daily reality of the elderly, we chose not to check on it.
Within the concept of the disablement process, disability is the difference between enviromental demand and capability. In the present situation, GPs were only able to increase capability by prosthetic means. A systematic management of cases such as performed in the USA is not possible within the present set up of general practice.2,3 To reduce enviromental demand and influence personal factors, GPs need more support in terms of manpower and financing.
In this study, screening followed by intervention by the GP did not lead to measurable effects for elderly people at the population level; it did show some effects in individuals. When considering the cost-effectiveness of the screening programme, the gains of screening all elderly people are small compared with the effort involved. Most disorders of old age develop well before the age of 75 years. As the group of people aged 75 years and over is heterogeneous, screening may even be too early for some of them. For others, it is too late because the moment at which an intervention could have been successful has already passed.
In conclusion, we do not recommend screening all elderly people in the way in which we did. Nevertheless, special attention should be paid to the highly prevalent disorders of old age. Assessments should be performed in a flexible way, focused on the individual needs of the elderly. The high consultation rate of the elderly population makes ‘case finding’ as a method of screening feasible. By analysis of consultation patterns, those who are becoming disabled and are in need of more detailed assessment may be identified.22 The recent introduction of practice nurses in Dutch general practices may give GPs the opportunity to make preventive primary care feasible.
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