A Comparative Study of Health Checkup Results between Early and Late Elderly

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1 Original Article A Comparative Study of Health Checkup Results between Early and Late Elderly Keito Torikai, MD, PhD 1), Nobuyoshi Narita, MD, PhD 1), Takahide Matsuda, MD, PhD 1), Yuko Tohyo, MD, PhD 2), Fumihiko Miyake, MD, PhD 2), Midori Narita, MD, PhD 3), Satoshi Imamura, MD, PhD 4), and Hiroki Sugimori, MD, PhD, MMedSc 5) 1) 2) 3) 4) 5) Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan Shibuya Sleep Medical Clinic, Tokyo, Japan Imamura Hospital, Fukushima, Japan Department of Preventive Medicine, Graduate School of Sports and Health Science, Daito Bunka University, Saitama, Japan OBJECTIVE: The present study assessed the validity of the benchmark, 75 years old, that divides elderly people into an early and a late stage, based on health checkup results for two consecutive years. We also investigated prevalent health problems and improvement trends. METHODS: This retrospective study was conducted on 1,416 subjects (1,007 early and 409 late elderly subjects) who received health checkups at the Health Care Center of the St. Marianna University School of Medicine Hospital between April 2006 and March The survey consisted of blood pressure, required blood test results, diagnoses according to the criteria defined by Kawasaki city, outcomes, and the presence or absence of a primary care doctor. RESULTS: The number of subjects with anemia and/or renal dysfunction was significantly greater in the late elderly than the early elderly (p<0.01). The results of the survey demonstrated that 79.6% of the early elderly and 87.4% of the late elderly had primary care doctors (p<0.01). In the early elderly, 57.0% of the subjects with Author for Corresponding: Keito Torikai, MD, PhD Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine Sugao, Miyamae-ku, Kawasaki-shi, Kanagawa, , Japan Tel: (Ext: 3640) Fax: k-tori@marianna-u.ac.jp Received for publication 8 July 2010 and accepted in revised form 15 November

2 General Medicine vol. 12 no. 1,2011 primary care doctors and 43.2% of those without primary care doctors showed improvement; the subjects with primary care doctors showed significant improvement compared to those without primary care doctors (p<0.05). In the late elderly, 50.2% of the subjects with primary care doctors and 54.2% of those without primary care doctors showed improvement, resulting in no significant difference between the subjects with and without primary care doctors. CONCLUSIONS: We found differences in the detected health problems and outcomes between the early and late elderly. These results support the appropriateness of the current age segmentation and future prospects for medical care in detecting and managing health problems in the elderly. KEY WORDS: the late elderly, the early elderly, health checkups for the elderly, primary care doctors, metabolic syndrome, geriatric medicine Gen Med : 2011 ; 12 : INTRODUCTION Since the 1950s, medical treatment, prevention of tuberculosis, and reduced infant mortality, which were regarded as the main causes of death, have contributed to improvements in average life expectancies in Japan. Nowadays, stroke, cancer and heart disease are the most commonly recognized causes of death; the number of patients who die of one of these diseases is increasing. The government and medical institutes have named these adult diseases, more recently calling them life-stylerelated diseases. Nowadays, there is growing acceptance of the concept of metabolic syndrome. In an aging society, it is important to discover risk factors for life-style related disease among the elderly as soon as possible to prevent progression or exacerbation of diseases, as well as to extend individuals independent lives and minimize the periods of health care dependency. 1 In 1963, the Welfare Law for the Aged came into effect. Later, in 1983, the Health and Medical Service Law for the Aged was enacted, establishing a basic health checkup, a method unique to Japan, for prevention and management of health problems. Local governments routinely provided annual health checkups for all residents aged 65 once a year under this law until March However, elderly people have little awareness of the importance of health checkups in disease detection, 2 and only a handful of follow-up surveys have been conducted. Therefore, we conducted a series of follow-up surveys to evaluate the effectiveness of health checkups and to determine whether health checkups and the presence of primary care doctors contribute to an improvement in detected health problems. 3,4 Among the elderly, those aged are classified as early-stage elderly (the early elderly) and those aged 75 are classified as late-stage elderly (the late elderly). In 2007, 427 million elderly people received long-term care: 84.7% of those were late elderly. Only 5% of the early elderly was certified as requiring long-term care, while approximately 30% of the late elderly needed longterm care. Most of the late elderly required longterm care. 5 In April 2008, a late-stage medical care system for the elderly was established based on the medical needs and life spans of elderly people. Since then, however, the usefulness of the late-stage medical care system for the elderly has remained uncertain. In the present study we assessed the appropriateness of the current age segmentation for this system, compared the results of health checkups between the two stages, and investigated differences in detected health problems and later improvements. METHODS This study was conducted at the Health Care 12

3 Table 1. Normal range in Follow-up survey Center of the St. Marianna University School of Medicine Hospital, a 1,200-bed facility. Among the subjects who lived near the hospital and those who were our outpatients, 1,416 subjects (mean age of 72.0 ± 5.5 years, 763 males and 653 females) who received health checkups at our Health Care Center between April 2006 and March 2007 were enrolled. The study subjects were stratified into two categories, the early elderly (n = 1,007) and the late elderly (n = 409). This retrospective cohort study was based on medical records and health checkup results. The survey items were blood pressure, required blood test results, diagnoses based on Kawasaki City standard (Table 1), outcomes, and whether or not they had primary care doctors. Statistical analysis was performed according to the χ ²test, and p value less than 0.05 was considered to indicate statistical significance. All analysis was performed using SAS programs (version 8.02, SAS Institute Inc., Cary, NC, USA). The Ethics Committee of the St. Marianna University School of Medicine Hospital authorized this study (authorization number 1120). RESULTS Of the 1,416 subjects, 1,322 subjects (716 males and 606 females, mean age of 72.0 ± 5.4 years) completed the study, including 942 of the 1,007 early elderly subjects (mean age of 69.1 ± 2.7 years, 488 males and 454 females) and 380 of the 409 late elderly subjects (mean age of 79.0 ± 3.8 years, 228 males and 152 females). Detected health problems Health problems were detected in 827 of the 942 early elderly subjects (87.8%) and 343 of the 380 late elderly subjects (90.3%). Detected health problems were as follows: hyperlipidemia (n = 388, 41.1%); hypertension (n = 346, 36.7%); diabetes mellitus (n = 222, 23.5%); liver dysfunction (n = 145, 15.3%); anemia (n = 75, 7.9%); and, renal dysfunction (n = 58, 6.1%) in the early elderly; and, hypertension (n = 159, 41.8%); hyperlipidemia (n = 149, 39.2%); diabetes mellitus (n = 72, 18.9%); anemia (n = 59, 15.5%); liver dysfunction (n 13

4 General Medicine vol. 12 no. 1,2011 Figure 1. Detected health problems = 44, 11.5%); and, renal dysfunction (n = 40, 10.5%) in the late elderly (Fig. 1). The number of subjects with anemia and/or renal dysfunction was significantly greater in the late elderly than the early elderly (p < 0.01). Outcomes Of the early elderly, 104 subjects received their first health checkups during the study period. Of the remaining 838 early elderly, 462 subjects (55.1%) received consecutive health checkups the following year. Of the 380 late elderly, 231 subjects (60.8%) returned to receive health checkups for two consecutive years. Improvement was defined as when patients baseline conditions returned to within the normal range during the intervening year, and deterioration was defined as when patients baseline conditions, which were previously within the normal range, exacerbated into the abnormal range. In subjects who had several health problems, improvement was defined as when one of their health problems returned to within the normal range. Of the returning subjects, 239 early elderly (51.7%) and 115 late elderly (49.8%) showed improvement over the year, demonstrating no difference between the two stages. Among the early elderly, 65 of the 191 subjects with hyperlipidemia (34.0%), 72 of the 178 subjects with hypertension (43.8%), and 48 of the 124 subjects with diabetes mellitus (38.7%) showed improvement. Among the late elderly, 21 of the 83 subjects with hyperlipidemia (25.3%), 35 of the 89 subjects with hypertension (39.3%), and 20 of the 52 subjects with diabetes mellitus (38.4%) showed improvement (Fig. 2). The presence or absence of primary care doctors The presence of primary care doctors was determined based on subjects answers during the survey. In the present study, 724 subjects of the 942 early elderly (76.9%) and 332 subjects of the 380 late elderly (87.4%) answered that they had primary care doctors (p < 0.01). Of these, 437 early elderly (60.4%) and 222 late elderly (66.9%) were treated in our hospital. Of the returning subjects in the early elderly, 23 subjects, who had no health problems at the first checkup, remained healthy; 204 of the 358 subjects with primary care doctors (57.0%) and 35 of the 81 subjects without primary care doctors (43.2%) showed improvement (p < 0.05). Of the returning subjects in the late elderly, 4 subjects remained healthy for two consecutive years; 102 of the 203 subjects with primary care doctors (50.2%) and 13 of the 24 subjects without primary care doctors (54.2%) 14

Figure 2. Improvement in detected health problems among returning subjects Figure 3.

primary care doctors showed improvement (N.S.).

improvement after a previous health checkup was significantly greater than those showing

However, we found no difference in the improvement of detected health problems between

In addition, there was no improvement rate difference in detected health problems between

DISCUSSION Aging process can be observed in the early elderly, and in the late elderly

5 Figure 2. Improvement in detected health problems among returning subjects Figure 3. Improvement in detected health problems comparing subjects with and subjects without primary care doctors showed improvement (N.S.). Among the early elderly, the number of subjects who had primary care doctors and showed improvement after a previous health checkup was significantly greater than those showing improvement without primary care doctors. However, we found no difference in the improvement of detected health problems between the late elderly with and the late elderly without primary care doctors (Fig. 3). In addition, there was no improvement rate difference in detected health problems between the early and the late elderly with primary care doctors (N.S.). DISCUSSION Aging process can be observed in the early elderly, and in the late elderly the underlying aging process is accelerated: the number of late elderly with chronic diseases, such as arteriosclerosis, increases remarkably. Decreased activity in daily life is closely associated with these diseases. 6 15

6 General Medicine vol. 12 no. 1,2011 In addition, the concept of metabolic syndrome, consisting of lifestyle related diseases, such as hypertension, hyperlipidemia, and diabetes mellitus is widely accepted these days. In the present study, we found no significant differences in the prevalence of lifestyle-related diseases between the early and late elderly. However, significant differences in anemia and renal dysfunction were observed between the two stages, and we assumed decreased nutritional intake due to aging and consumption attributed to the increased prevalence of anemia in the late elderly. 7 Sequential occurrence caused by carcinoma and a decrease in bone marrow function because of aging are also associated with the late elderly. 8 Renal function is affected by not only renal diseases but also by ageing. The elderly have a higher prevalence of chronic renal failure than the young and middle aged. 9 We considered that these factors affected the present study results. The number of subjects with anemia and/or renal dysfunction is greater among the late elderly than among the early elderly. Accordingly, it is necessary to establish a new health checkup system, including more checkup items designed to detect anemia and renal dysfunction depending on the age of the elderly. When considering the improvement of detected health problems, we found no differences between t h e e a r l y a n d t h e l a t e e l d e r l y. R e g a r d i n g hypertension, a Very Elderly Trial found that antihypertensive treatment among the elderly 80 years old is beneficial and antihypertensives should be administered. 10 One study has suggested that hypertensive treatment should aim to achieve a target blood pressure of 140 / 90 mmhg for the improvement of prognosis in the early and late elderly. 11 To date, there is no definite evidence of diabetes mellitus, which defines a different target in the early and late elderly. 12 Management based on diagnostic criteria of hyperlipidemia is necessary not only for the early elderly but also for the late elderly who live normal lives and have high risks, such as diabetes mellitus. 13 Since the present study demonstrated no difference in the improvement of hypertension, diabetes mellitus, and hyperlipidemia between the early and the late elderly, diagnostic criteria and aggressive treatment should be indispensable even in the late elderly. Accordingly, the same guidelines for these diseases should be required for both the early and the late elderly. Our previous study reported that the number of elderly people who have primary care doctors is increasing with aging. 14 We have also demonstrated that the elderly aged 65 years with primary care doctors show improvement over the previous year. 15 In the present study, the early elderly with primary care doctors showed improvement, which was similar to the results of our previous study. However, the late elderly with primary care doctors showed no remarkable improvement. We presume this is due to the fact that many late elderly people have severe diseases. We therefore believe that classification of the elderly is necessary to detect health problems in the early stages and to prevent the exacerbation of these problems. In addition, the early elderly should have primary care doctors with whom they can consult regarding their health problems. There was no significant difference in the improvement of detected health problems between the subjects with primary care doctors in the early and the late elderly. More detailed evaluation and a more aggressive approach are required even in the later elderly years. As this study was conducted at the University School of Medicine Hospital to which many subjects presented with health problems, the morbidity in subjects who received annual health checkups might be higher than in those who received checkups in clinics engaging in community health. Moreover, this study did not include subjects quality of life in the checkup items. Further studies with more checkup items and detailed classification of the elderly are thus called for. CONCLUSIONS In the present study we could observe differences in detected health problems between the early and the late elderly. It is necessary for us to reconsider the health checkup system, including different checkup items depending on the ages of the elderly, though some factors showed no differences between 16

7 the early and the late elderly. In addition, further studies should be undertaken in order to evaluate the appropriateness of age segmentation. The abstract of this study was presented at the 45th Meeting of the Japanese Society of Clinical Physiology and the 31st Meeting of The Japanese Medical Society of Primary Care. References 1. Suzuki, T.; Iwasa, H.; Hu, X. et al. Comprehensive health examination ("Otasha-kenshin") for the prevention of geriatric syndromes and a bed-ridden state in the community elderly (in Japanese). Japanese Journal of Public Health. 2003, vol.50, p Ohuchi, Y. Necessity and the role of medical treatment for the aged (in Japanese). Jpn J Internal Med. 2004, vol.93, p Narita, N. ; Narita, M., Nishiyama, M. et al. The significance of health checkups for the elderly in St.Marianna University Hospital. Primary Care Japan. 2005, vol.3, p Narita, N.; Nobuoka, S.; Hara, M. et al. Follow-up study of elderly people who return for health checkups. Jpn J Clin Physiol. 2007, vol.37, p Sakai, S. The elderly (in Japanese). Handbook to medical treatment in the elderly. Tokyo: Nikkei Medical Custom Publishing, Inc., Suzuki, N.; Makigami, K.; Goto, A.; Yokokawa, H., and Yasumura, S. Comparison of ability-based and performance-based IADL evaluation of communitydwelling elderly using the Kihon Checklist and TMIG Index of Competence (in Japanese). Jpn J Geriat. 2007, vol.44, p Funatsu, K.; Yamashita, T.; Honma, M., et al. Study of value in clinical examination in the elderly at nursing home (in Japanese). Prog Med. 2006, vol.26, p Itano, R. ; Otani, Y., Nishio, I. et al. Clinical examination of the elderly health checkups in Nara city (in Japanese). Jpn Med J. 1989, vol.3411, p Fujii, H. ; Fukagawa, M. Acute and Chronic Renal Failure (in Japanese). Manual for medical treatment in the elderly. Tokyo: Japan Medical Association, Beckett, N. S., Peters, R., Fletcher, A. E., et al. Treatment of hypertension in patients 80 years of age or elder. N Engl J Med. 2008, vol.358, p The Japanese Society of Hypertension Committee. The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH2009) (in Japanese). Tokyo : Life Science Publishing Co., Ltd ; Kinbara, Y.; Araki, A.; Tamura, Y.; Mori, S., and Ifuji, E. Treatment of old old patients with diabetes mellitus (in Japanese). Clinic All-Round. 2008, vol.57, p Teramoto, T. Japan Atherosclerosis Society Guideline for Diagnosis and Prevention of Atherosclerotic Cardiovascular Diseases for Japanese (in Japanese). J Jpn Coll Angio. 2008, vol.48, p Torikai, K.; Narita, N.; Nobuoka, S., et al. Followup study on the elderly health checkups. Primary Care Japan. 2007, vol.5, p Torikai, K.; Narita, N.; Takeoka, H. et al. Significance and effectiveness of health checkups for the elderly. Jpn J Clin Physiol. 2008, vol.38, p

Health Checkup for the Elderly in the St. Marianna University School of Medicine Hospital

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