Adults and Older AdultsCounseling

Substance abuse, defined as the harmful or hazardous use of alcohol, tobacco, or other legal and illegal drugs, is a leading cause of death and disability in United States. Alcohol and drug abuse are physically damaging and are associated with other leading causes of death, including accidents, suicide, homicide, and HIV infection.

Alcohol abuse is estimated to cost society approximately $85.8 billion annually -- nearly twice as much as the abuse of all other drugs combined. Alcohol abuse alone is associated with a dramatic proportion of traffic fatalities (41%), drownings and murders (67%), deaths in fires (70% to 80%), and suicides (35%). Consumption of alcohol during pregnancy can lead to development of fetal alcohol syndrome (FAS), which can produce a variety of deleterious effects ranging from physical anomalies to mental impairment to more subtle cognitive and behavioral dysfunctions. According to the Centers for Disease Control and Prevention an estimated 1 in 3,000 births are affected by FAS each year (Selected References).

Abuse of drugs other than alcohol is estimated to cost society approximately $47 billion per year. Illicit drug use contributes to both social and medical problems. An estimated 5.5 million Americans are affected by drug abuse or dependence, half of whom are within the criminal justice system. Injection drug use and use of crack are major contributors to the spread of HIV. Drug use is also integrally related to problems such as accidents, homicide, and suicide. Estimates of the extent of prescription drug misuse vary, but there is little doubt that misuse of legal medications is responsible for a significant portion of the morbidity and mortality associated with substance abuse. One authority indicates that a 60% to 70% of patients treated in emergency rooms for drug-related episodes are misusing prescription drugs.

According to the National Institute on Drug Abuse, the overall prevalence of drug use does not differ between Caucasian, African American, and Hispanic populations although patterns of use may differ. Primary care providers often fail to recognize alcohol and drug abuse problems in their patients. Some studies report detection rates as low as 30%. Minimal interventions by primary care clinicians, such as advice to modify current use patterns and warnings about adverse health consequences, can have beneficial effects, especially for patients in the early stages of addiction. More intensive interventions, such as referral to outpatient or inpatient/residential treatment facilities, can be life-saving for patients in more advanced stages of alcohol and other drug dependence.

See chapter 18 for information on counseling children and adolescents on alcohol and other drug abuse. See chapter 24 for information on counseling children and adolescents about tobacco use prevention and chapter 60 for information about counseling adults on smoking cessation.

American College of Obstetricians and Gynecologists --

Women should be asked about their use of alcohol and other drugs.

American College of Physicians --

The physician's role in recognizing and treating chemical dependence requires knowledge of the symptoms of chronic and excessive drug use and increased sensitivity to and awareness of behavior associated with such problem use. The physician's role in preventing chemical dependency includes patient education and counseling about the appropriate use of substances upon which dependence is likely. Thoughtful and knowledgeable prescribing practices that minimize the likelihood of producing or maintaining iatrogenic chemical dependence are essential.

American Medical Association --

All physicians with clinical responsibility for diagnosis of and referral for alcoholism and drug abuse problems should be able to recognize alcohol or drug-caused dysfunction and should be aware of the medical complications, symptoms, and syndromes with which alcoholism or drug abuse commonly presents. All complete health examinations should include an in-depth history of alcohol and other drug use. The physician should evaluate patient requirements and community resources so that an adequate level of care may be prescribed, with patients' needs matched to appropriate resources and with referrals made to a resource that provides appropriate medical care.

Canadian Task Force on the Periodic Health Examination --

Routine active case-finding of problem drinking is highly recommended on the basis of the high prevalence of this problem among patients in medical practices, its association with adverse consequences before the stage of dependency is reached, and its amenability to a counseling intervention by clinicians. Detection of biomarkers is not recommended, although this may be useful to confirm suspicions raised by use of patient administered questionnaires (eg, Alcohol Use Disorders Identification Test [AUDIT], the Michigan Alcoholism Screening Test [MAST] and the Drug Abuse Screening Test [DAST]).

US Preventive Services Task Force --

Screening to detect problem drinking is recommended for all adult and adolescent patients. Screening should involve a careful history of alcohol use and/or the use of standardized screening questionnaires. Routine measurement of biochemical markers is not recommended in asymptomatic persons. Pregnant women should be advised to limit or cease drinking during pregnancy. Although there is insufficient evidence to prove or disprove harm from light drinking in pregnancy, recommendations that women abstain from alcohol during pregnancy may be made on other grounds. All persons who use alcohol should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking alcohol.

There is insufficient evidence to recommend for or against routine screening for drug abuse with standardized questionnaires or biologic assays. Including questions about drug use and drug-related problems when taking a history from all adolescents and adult patients may be recommended on other grounds including the prevalence of drug use and the serious consequences of drug abuse and dependence. All pregnant women should be advised of the potential adverse effects of drug use on the development of the fetus. Clinicians should be alert to the signs and symptoms of drug abuse in patients and refer drug abusing patients to specialized treatment facilities where available.

Identifying patients with substance abuse problems is critical. Begin history-taking with questions about relatively nonthreatening subjects -- such as the number of cups of caffeinated beverages the patient drinks per day -- before moving on to questions about the types, amounts, duration, and patterns of use of legal and illegal substances. When asking questions about frequency and use, be aware that there may be a tendency among patients to under-report use. However, such questions may be helpful in identifying individuals who drink large quantities (eg, binge drinkers). Questions about the negative consequences of abuse can also be helpful in assessing the magnitude of the problem. Areas that may be addressed include: driving history, employment history, educational progress, legal problems, family life, social activities, and enrollment in treatment programs. Asking about family history of substance abuse will help assess the patient's genetic vulnerability. If the patient has made previous attempts to stop or moderate use of alcohol or drugs, ask about the methods, barriers encountered, and degree of success. Table 53.1 and Figure 53.1 outline the screening algorithm recommended by the National Institute on Alcohol Abuse and Alcoholism. Table 53.2 provides sample questions for taking clinical histories about drug use.

Brief, self-administered screening questionnaires can help identify patients in need of more detailed evaluation. Examples of such tools include: the Alcohol Use Disorders Identification Test (AUDIT), the Michigan Alcoholism Screening Test (MAST), and the Drug Abuse Screening Test (DAST). See Provider Resources.

Ask the patient about physical symptoms of substance abuse. Examples include frequent headaches or other chronic tension states, absence from work based on vague physical complaints, insomnia, unexplained mood changes, gastrointestinal disorders, uncontrolled hypertension, impotence and other sexual disorders, and neuropathies.

The physical examination is a relatively insensitive and nonspecific method of detecting alcohol or drug abuse. Some signs of alcohol abuse include weight gain or loss, labile or refractory hypertension, abnormal skin vascularization, conjunctival injection, tongue or hand tremor, epigastric tenderness, and hepatomegaly. Cocaine users may have damaged nasal mucosa and weight loss. Injection drug users may have hypodermic marks. Signs of previous or current trauma are other clues to substance abuse problems.

Laboratory tests, such as measurement of liver enzymes and erythrocyte mean corpuscular volume, are helpful in evaluating physiological damage but are not good screening tools for detecting alcohol abuse. Determination of the gamma-glutamyl transferase (GGT) level is the most sensitive biochemical test for alcohol abuse, but this test has a sensitivity of only 25% to 36%. Screening of urine for drugs can help confirm drug use, but such screening provides no information about the quantity or frequency of use. An estimated 5% to 30% of positive drug screens are false positives, depending on the drug, the method of analysis, and the population being tested. In general, these tests should not be used as screening tools in the primary care setting, and certainly they should not be used without patient consent.

Express genuine concern and maintain an honest, nonjudgmental approach with substance-abuse patients. Avoid arguing with, confronting, or labeling the patient. Attempt to maintain a partnership with the patient, functioning as an expert consultant. Trust is essential; assure the patient that any information disclosed will be kept confidential to the maximum extent possible.

This policy should apply to use of tobacco, alcohol, and other drugs. Counseling a patient who is under the influence of alcohol or other drugs is not productive and may be counterproductive because of the indirect encouragement of abuse that it gives to the patient. Schedule return appointments for such patients to occur when they are not under the influence.

Present such information in a straightforward, nonjudgmental manner. For example, "Your trouble sleeping, the difficulty in controlling your blood pressure, and the recent problems at home with your family make me concerned that alcohol may be the main problem. I would like to discuss this possibility with you more. Warn injection drug users about the risk of HIV infection, hepatitis B infection, and other disorders associated with using contaminated or shared needles. Counseling for injection drug users should also involve proper screening for conditions including infectious hepatitis and HIV (chapters 48 and 59).

Convey to the patient a sense of optimism and confidence that he or she can control his or her substance use.

Communicate clearly and firmly to the patient a recommendation to stop substance abuse. Assist the patient in setting a date for abstinence or goals for step-wise moderation of substance use. Help the patient to anticipate physiologic and psychologic withdrawal symptoms and to plan for potential relapses or "slips."

The assistance and patience of family members can be critical for the success of the patient's efforts at abstinence or moderation. Involve others only with the patient's consent.

Many patients may benefit from the structure provided by peer counseling, support groups, in-patient treatment, and other modalities. Become familiar with support and treatment resources available in the community so that appropriate referrals, if needed, can be made.

Monitoring and supporting patient success is essential and desirable, even for patients referred for treatment. Schedule return appointments at regular intervals, particularly during the first weeks of each patient's efforts to stop or moderate use.

Alcohol: What to Do If It's a Problem for You. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Alcohol and Women. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Drugs and Pregnancy: Often the Two Don't Mix. FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Let's Talk Facts about Substance Abuse. American Psychiatric Association, 1400 K St, NW, Washington, DC 20005; (800)368-5777. Internet address: http://www.psych.org

National Clearinghouse for Alcohol and Drug Information. For information about the numerous publications that are available in both English and Spanish, call: (800)729-6686.

Drug Abuse Screening Test. Internet address: http://www.nida.nih.gov/Diagnosis-Treatment/DAST10.html

Michigan Alcohol Screening Test. Internet address: http://www.silcom.com/~sbadp/treatment/mast.htm

The Physician's Guide to Helping Patients With Alcohol Problems. National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. 95-3769. 1995. Internet address: http://silk.nih.gov/silk/niaaa1/publication/physicn.htm

Table 53.1. Screening Procedures for Alcohol-Related Problems

Table 53.2. Examples of Questions for Taking Clinical Histories About Drug Use

Most Americans are affected by dental and oral health problems at some point in their lives. The most common problems are dental caries (tooth decay) and periodontal diseases, both of which are largely preventable. Although dental caries is more commonly thought of as a childhood disease, adults continue to be at risk for dental decay throughout their lives. The Third National Health and Nutrition Examination Survey (NHANES III) found that 94% of persons older than age 18 years had either untreated decay or fillings in the crowns of their teeth. On average, American adults had 22 decayed or filled coronal surfaces. Root-surface decay associated with gingival recession is a particular concern in older adults. Moderate loss of gingival attachment was present in almost 40% of all Americans. This problem increased significantly with age: 82% of persons older than age 65 years had attachment loss. Periodontal diseases and caries are the predominant causes of tooth loss. Oral mucosal lesions of all types are also prevalent (10% to 25%) in adult and elderly populations.

Numerous clinical trials have demonstrated that personal oral hygiene measures can help control plaque and gingivitis in most individuals. Progression of periodontal diseases can be retarded by the combination of excellent personal oral hygiene practices and regular professional care. Routine use of dentifrices with fluoride has been shown to prevent both coronal and rootsurface caries in adult populations.

Oral cancer is also a major concern among adults. In the United States, one person dies from cancers of the oral cavity and pharynx every hour (8000 deaths annually). Some 30,000 individuals are diagnosed with these cancers each year -- 2% of cancers diagnosed in the US. Men are affected twice as often as women, and 90% of these cancers occur in those over 45 years of age. Use of tobacco in all forms and heavy consumption of alcohol are major causal factors.

See chapter 19 for information on counseling children and adolescents on dental and oral health. See chapter 30 for a discussion of the oral cavity examination.

American Cancer Society --

Patients should be counseled about oral health during cancer-related checkups, which should occur every 3 years for those aged 20 to 40 years, and then yearly for those over 40.

American College of Obstetricians and Gynecologists --

Dental hygiene should be included in counseling as part of periodic evaluation visits, which should occur yearly or as appropriate.

American Dental Association --

Adults should be seen for routine dental care, preventive services, including oral cancer screening, and oral hygiene counseling at least once every year. This recommendation applies to patients with full dentures as well as patients "with teeth."

Canadian Task Force on the Periodic Health Examination --

There is good evidence that the following clinical or personal interventions are effective in preventing dental caries: use of dentifrices containing fluoride; fluoride supplements for patients in areas where there is a low level (0.3 ppm or less) of fluoride in the drinking water; professionally applied topical fluoride and the use of fluoride mouth rinses for patients with very active decay or at a high risk of dental caries; and a selective use of professionally applied fissure sealants on permanent molar teeth. There is poor evidence for: fluoride treatments and fluoride mouth rinses for patients with a low risk of caries; toothbrushing (without a dentifrice containing fluoride) and flossing; professional cleaning of teeth before a fluoride treatment or at a dental visit; and dietary counseling for the general population. There is good evidence to recommend against the use of over-the-counter fluoride mouth rinses by the general population.

US Preventive Services Task Force --

Counseling patients to visit a dental provider on a regular basis is recommended based on evidence for risk reduction from such visits when combined with regular personal oral hygiene; the effectiveness of advising patients to visit a dental care provider has not been evaluated. There is little evidence regarding the optimal frequency of visits; this recommendation should be made by the patient's dental care provider. Counseling all patients to brush their teeth daily with fluoride-containing toothpaste and to clean thoroughly between their teeth with dental floss each day is recommended based on the proven efficacy of risk reduction from doing so; the effectiveness of clinician counseling to encourage these behaviors has not been adequately evaluated. When examining the mouth, clinicians should be alert for obvious signs of untreated tooth decay or mottling, inflamed or cyanotic gingiva, loose teeth, and severe halitosis and for signs and symptoms of oral cancer and premalignancy in persons who use tobacco or excessive amounts of alcohol.

Dental Emergency Procedures; Seal Out Decay; Smokeless Tobacco: Think Before You Chew. American Dental Association, Department of Salable Materials, 211 E Chicago Ave, Chicago, IL 60611; (800)947-4746.

Diet and Dental Health; Smoking Can Really Do a Number on Your Health; Oral Health Care Guidelines for Special Patients (11 different guideline booklets). To order these and other materials, contact the American Dental Association, Department of Salable Materials, 211 E Chicago Ave, Chicago, IL 60611; (800)947-4746.

For a Lifetime of Smiles.... To order this and other material, contact the American Dental Hygienists' Association, 444 N Michigan Ave, Suite 3400, Chicago, IL 60611; (312)440-8900. Internet address: http://www.adha.org

Dental Tips for Diabetics (English and Spanish); Dry Mouth (Xerostomia); Fever Blisters and Canker Sores; Fluorides Aren't Just for Kids (poster); Periodontal Disease and Diabetes: A Guide for Patients; Fluoride to Protect the Teeth of Adults. National Institute of Dental Research, Bldg 31 Room 2C35, 31 Center Dr, MSC 2290, Bethesda, MD 20890-2290; (301)496-4261. Internet address: http://www.nidr.nih.gov

What You Need to Know About Oral Cancer. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda MD 20892; (800)4-CANCER.

Detection and Prevention of Periodontal Disease: A Guide for Health Care Providers. National Institute of Dental Research, Bldg 31, Room 2C35, 31 Center Dr, MSC 2290, Bethesda MD, 20890-2290; (301)496-4261. Internet address: http://www.nidr.nih.gov

Getting the Picture on Dental X Rays. To order this and other publications, contact the FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Table 54.1. Effects of Selected Drugs

Table 54.2. Cardiac Conditions * for Which Endocarditis Prophylaxis Is and Is Not Recommended

Table 54.3. Standard Antibiotic Prophylaxis Regimens for Dental or Operative Procedures in the Oral Cavity of Patients Subject to Bacterial Endocarditis *

Unintentional injuries are the fifth leading cause of death in the United States and the leading cause of death among persons ages 1 to 44 years. Motor vehicle crashes account for half of all unintentional injury deaths. Alcohol is a contributing factor in 20% of non-fatal and 40% of fatal motor vehicle crashes. Nationwide, seat belt use is estimated to be 68%; however, in fatal crashes, seat belt use is lower than 50%. Other major causes of unintentional injury deaths are falls, poisoning, drowning, and residential fires.

Unintentional injury is also a major cause of morbidity and mortality for older adults. Falls are the second leading cause of injury death for adults ages 65-84 years and the leading cause of injury death for those 85 years and older. The number of deaths attributable to falls in the group aged 65 to 74 years is twice that in the general population; among persons older than age 85 years, the fall-related death rate is 15 times that in the general population. Hip fracture is the most common fall-related injury leading to hospitalization in older adults. Roughly half of all persons sustaining hip fractures never regain full function. According to Lindsay, annual expenditures in the United States related to hip fractures are estimated to be between $10 and $20 billion.

Domestic violence is an important health risk for many women. Injury to women as a result of partner abuse is of special concern to primary care clinicians since high rates of violent assault have been detected in patients seen in general medical practices, prenatal clinics, urgent care centers and emergency departments. Although the majority of adults abused by their partners are females, men are also affected by partner violence. Estimates of the magnitude of partner violence vary depending on the data source. Bachman and Saltzman found that over 1 million women and nearly 150,000 men are victims of partner violence each year. Other investigators report that between 2 and 4 million American women each year are victims of partner abuse and that more than 1 million women seek assistance for injuries caused by battering. Abuse of women knows no socioeconomic, racial, ethnic, religious, or age barriers. The risk for domestic violence increases during pregnancy and after separation or divorce. The consequences of partner abuse are serious and alarming ranging from injury to aggravated battery to death. In approximately 30% of all female homicides in the US, the killer is an intimate.

Although primary care clinicians treat a wide range of injuries, studies indicate that they deliver little counseling to adults about injury prevention and do not detect and treat domestic violence in an optimal manner. Considering the amount of death and disability caused by preventable injuries and violence, these topics should be discussed with all patients.

See chapter 26 for information on counseling children and adolescents on violent behavior and firearms; chapter 22 for related information on counseling children and adolescents on safety; chapter 5 for information about screening children and adolescents for depression and suicide; and chapter 33 for information about screening adults for depression.

Most major authorities, including American College of Physicians, Canadian Task Force on the Periodic Health Examination, National Transportation Safety Board, and US Preventive Services Task Force -- Health-care professionals should counsel patients on automobile safety restraint use.

American Academy of Family Physicians --

Counsel about unintentional injury prevention, including, as appropriate, child safety seats, lap and shoulder belt use, bicycle safety, motorcycle helmet use, smoke detectors, poison control center numbers, and driving while intoxicated.

American College of Obstetricians and Gynecologists --

Injury prevention should be part of the evaluation and counseling portions of the periodic examination of women of all ages, with particular attention to safety belts and safety helmets, firearms, recreational and occupational hazards, and sports involvement.

Canadian Task Force on the Periodic Health Examination --

Expert opinion suggests that many patients seen by clinicians could potentially benefit from counseling to modify their injury prone behaviors. In actual practice, however, it is not known how effectively clinicians can alter these behaviors. Since unintentional injuries represent a leading cause of death and nonfatal injury, even modest successes through clinical interventions could have major public health value. Counseling is most relevant for those at increased risk of injury, such as adolescents and young adults, persons who use alcohol and other drugs, and persons with medical conditions that may impair motor vehicle safety. The optimal frequency for counseling patients about unintentional injury has not been determined and is left to clinical discretion. There is insufficient evidence to support including assessment and counseling of elderly patients for the risk of falling in the routine health examination of the elderly. It may be included, however, on other grounds. There is good evidence for referring elderly patients to multidisciplinary post-fall assessment teams where such a service is available.

US Preventive Services Task Force --

Counseling to prevent household and environmental injuries is recommended for adolescents and adults based on the proven efficacy of risk reduction, although the effectiveness of counseling these patients to prevent injuries has not been adequately evaluated. Persons with alcohol or drug problems should be identified and counseled and their progress monitored. Those who use alcohol or illicit drugs should be warned against engaging in potentially dangerous activities while intoxicated. Counseling elderly patients on specific measures to reduce the risk of falling is recommended based on fair evidence that these measures reduce the risk of falls, although the effectiveness of counseling elders to prevent falls has not been adequately evaluated. There is insufficient evidence to recommend for or against the use of external hip protectors to prevent fall injuries, but recommendations for their use in institutionalized elderly may be made on other grounds. More intensive individualized multifactorial intervention is recommended for high-risk elderly patients in settings where adequate resources to deliver such services are available.

American College of Obstetricians and Gynecologists --

Women ages 19 to 64 should be counseled on domestic violence as part of periodic evaluation visits, which should occur yearly or as appropriate. Women ages 13 to 18 and over 65 should be counseled on abuse and neglect as part of periodic evaluation visits, which should occur yearly or as appropriate.

American Medical Association --

All female patients in emergency, surgical, primary care, pediatric, prenatal, and mental health settings should be screened for domestic violence. Every clinical setting should have a protocol for detection and assessment of elder mistreatment. The physician should assure that a comprehensive medical examination is conducted with elderly patients and the results documented. Physicians can play a critical role in identifying, treating, and preventing elder abuse and neglect in institutional settings. Physicians must be aware of the requirements for reporting elder abuse to adult protective services in the state(s) in which they practice.

American Nurses Association --

All women should receive routine assessment and documentation for physical abuse in any health care institution or community setting. Women at increased risk of abuse, such as pregnant women and women presenting in emergency rooms, should receive targeted assessment.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against the use of specific screening instruments for family violence, but including a few direct questions about abuse (physical violence or forced sexual activity) as part of the routine history in adult patients may be recommended on other grounds. These other grounds include the substantial prevalence of undetected abuse among adult female patients, the potential value of this information in the care of the patient, and the low cost and low risk of harm from such screening. All clinicians should be alert to physical and behavioral signs and symptoms associated with abuse and neglect. All individuals who present with multiple injuries and an implausible explanation should be evaluated with attention to possible abuse or neglect. Injured pregnant women and elderly patients should receive special consideration for this problem. Suspected cases of abuse should receive proper documentation of the incident and physical findings (eg, photographs, body maps); treatment of physical injuries; arrangements for counseling by a skilled mental health professional; and the telephone numbers of local crisis centers, shelters, and protective service agencies.

1. Counsel older adults or their caretakers to periodically:

• Inspect the home for adequate lighting
• Remove or repair floor structures that predispose to tripping, such as loose rugs, electrical cords, and toys
• Install handrails and traction strips in stairways and bathtubs
• Keep hot water set at 49° C (120° F) or lower.

Safety counseling can be facilitated by advising the patient or caretaker to use a home-safety checklist (Table 55-2). Home visits are also an excellent opportunity to assess home safety for older adults.

2. Periodically check the visual acuity (chapter 45) and assess the physical mobility of patients.

3. Avoid prescribing drugs that increase the risk of falls (ie, long-acting benzodiazepines, tricyclic antidepressants, major tranquilizers, and other sedatives); if such drugs are prescribed, closely monitor the patient. Many falls in older adults are attributable to side effects from polypharmacy (chapter 58).

4. Encourage older adults without medical contraindications to engage in an exercise program to maintain muscle and bone strength, mobility, and flexibility.

5. Assess the need for estrogen replacement therapy to help prevent fractures from osteoporosis in postmenopausal women (chapter 47). Also assess the need for counseling about weight-bearing exercises, calcium supplementation, and other nutritional issues in these women.

Auto Safety Hot Line. National Highway Traffic Safety Administration: (800)424-9393

National Highway Traffic Safety Administration, Office of Occupant Protection, NTS-13, 400 7th St, SW, Washington, DC 20590; (202)366-2727.

Age Page Accident Prevention and the Elderly; Age Page -- Preventing Falls and Fractures. National Institute on Aging, Bldg 31, Room 5C27, 31 Center Dr, MSC 2922, Bethesda, MD 20892-2922; (310)496-1752. Internet address: http://www.nih.gov/nia/health/pubpub/pubpub.htm

The Abused Woman. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024-2188; (202)638-5577. Internetaddress: http://www.agog.com

Your Home Safety Checklist; Preventing Falls: A Safety Program for Older Adults; Facts About Backs; Playing it Safe: A Pocket Guide to Fitness. To order these and other materials, contact the National Safety Council, 444 N Michigan Ave, Chicago, IL 60601; (800)621-7619, ext 1300.

US Consumer Product Safety Commission, Publication Requests, Washington, DC 20207. Pamphlets on preventing injuries from toys, household goods, and other common items. (800)638-2772 (English and Spanish).

US Consumer Product Safety Commission, Washington, DC 20207. Recorded messages in both English and Spanish. (800)638-2772.

Domestic Violence. ACOG Technical Bulletin No. 209. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024-2188; (202)638-5577. Internet address: http://www.acog.com

Diagnostic and Treatment Guidelines on Domestic Violence. American Medical Association, Department of Mental Health, 515 N State St, Chicago, IL 60610; (312)464-5066. Internet address: http://www.ama-assn.org

What Can You Do About Family Violence? (No. NC110992) American Medical Association, 515 N State St, Chicago, IL 60610; (800)621-8335. Internet address: http://www.ama-assn.org

Injury Control News. Association for the Advancement of Injury Control, Attn: Harry Teter, 888 17th St NW Suite 1000, Washington, DC 20006; (202)296-6161.

Auto Safety Hot Line. National Highway Traffic Safety Administration: (800)424-9393.

National Highway Traffic Safety Administration, Office of Occupant Protection, NTS-13, 400 7th St SW, Washington, DC 20590; (202)366-2727.

Understanding Violence Against Women (Crowell and Burgess, eds.). National Academy Press, 2101 Constitution Ave., NW, Washington DC 20418. (800)624-6242.

US Consumer Product Safety Commission, Washington, DC 20207. For recorded messages in both English and Spanish, call: (800)638-2772.

US Consumer Product Safety Commission, Publication Requests, Washington, DC 20207. Pamphlets on preventing injuries from toys, household goods, and other common items. (800)638-2772 (English and Spanish).

Falling The Unexpected Trip: A Safety Program for Older Adults

Table 55.1. Proper Safety Belt Use

Table 55.2. Home Safety Checklist for Older Adults

Table 55.3. Recommended Questions for Clinicians to Ask Potential Victims of Abuse

Four of the 10 leading causes of death in the United States -- heart disease, stroke, diabetes mellitus, and certain cancers -- are linked to diet. Together these diseases account for nearly two-thirds of the two million annual deaths in this country. Diet-related health conditions in the United States cost an estimated $250 billion annually in medical costs and lost productivity.

Over-consumption of calories, particularly from fat, and declining levels of physical activity have made overweight a major public health problem in the United States. Obesity ¹ is a risk factor for several chronic diseases, and the proportion of overweight Americans, presently over one-third, continues to increase. High sodium intake is associated with hypertension. High alcohol intake increases risk for hypertension, stroke, heart disease, and certain cancers. Under-consumption of nutrients such as calcium, iron, and folate causes health problems for some individuals, particularly women.

Good nutrition is essential to maintain good health throughout life, and dietary intervention is an important component of both the prevention and treatment of many chronic conditions. Patients often look to their primary care providers for nutritional guidance; simple, focused interventions by clinicians can be beneficial to patients.

See chapter 20 for information on nutrition counseling for children and chapter 29 for information on body measurement and obesity.

Most major authorities, including American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Physicians, American Dietetic Association, American Heart Association, Canadian Task Force on the Periodic Health Examination (CTFPHE), and US Preventive Services Task Force (USPSTF) -- Clinicians should routinely provide nutritional assessment and counseling to their patients. The USPSTF has stated that there is insufficient evidence that nutritional counseling by physicians has an advantage over dietitian counseling or community interventions in changing the dietary habits of patients. The AAFP targets obesity (for all patients over 2 years) and calcium intake (for females 11 years and over). AAFP recommends directing obese patients to replace calories from fat with increased dietary fiber and counseling age-appropriate females with regard to adequate calcium intake. The CTFPHE has stated that it is reasonable for physicians to provide general dietary advice, while for patients at increased risk, such as alcoholics and the elderly living alone, it is prudent to consider referral to a clinical nutritionist or other professional with specialized nutritional expertise.

The American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), US Preventive Services Task Force (USPSTF) and the Canadian Task Force on the Periodic Health Examination (CTFPHE)

recommend that women of childbearing age who are capable of becoming pregnant consume 0.4 mg of folic acid per day.

1. Weigh and measure every patient on a regular basis. Chapter 29 contains information on performing and assessing body measurement. Advise patients of their healthy weight range based on such factors as age, gender, and distribution of body fat.

2. Talk with all patients about their dietary habits. Ask them if they are taking any dietary supplements. Short patient questionnaires can be useful in identifying patients in need of more in-depth evaluation. See Table 56.1 for a brief questionnaire developed for screening older adults. Questionnaires for more general use have also been developed (see Block, et al, in Selected References).

3. Provide patients with basic information about managing a healthy diet. The US Department of Agriculture and the US Department of Health and Human Services recommend the following in their publication, Dietary Guidelines for Americans:

• Eat a variety of foods.
• Balance the food you eat with physical activity; maintain or improve your weight.
• Choose a diet with plenty of grain products, vegetables, and fruits.
• Choose a diet low in fat (less than 30% of calories), saturated fat (less than 10% of calories), and cholesterol (300 mg or less per day).
• Choose a diet moderate in sugars.
• Choose a diet moderate in salt and sodium (less than 2400 mg per day).
• If you drink alcoholic beverages, do so only in moderation (no more than one drink daily for women or 2 drinks daily for men). One drink is 12 oz of regular beer, 5 oz of wine, or 1.5 oz of 80-proof distilled spirits.

4. Use the Food Guide Pyramid (Figure 56.1) and the Nutrition Facts label (Figure 56.2) as educational tools for helping patients plan healthful diets.

5. Women have special dietary needs, particularly for calcium and folic acid. Counsel women of all ages to consume adequate calcium, which helps build optimal bone mass during the teen years and early adulthood and, after menopause, helps control bone loss and delay development of osteoporosis. Dairy products are major sources of calcium. Other sources of calcium are canned fish with soft bones, vegetables such as broccoli and spinach, and fortified cereals and grains. See Table 56.2 for calcium requirements. The National Academy of Science is expected to publish reference intakes for calcium in late 1997.

6. Advise women of the following options for consuming adequate amounts of folic acid:

• Consumption of a diet consistent with the Dietary Guidelines for Americans and the Food Guide Pyramid (Figure 56.1) is likely to provide the proper amount of folic acid. Some good sources are dry beans, leafy green vegetables, and citrus fruits.
• Consumption of fortified foods, such as breakfast cereals, may help patients consume enough folic acid.
• Folic acid-supplement pills and multivitamin preparations containing 0.4 mg folic acid are available.

Caution patients against consuming more than 1 mg of folic acid daily, because the effects of excess folic acid are not well known. Such effects may include a delay in the detection of vitamin B ₁₂ deficiency, thus allowing neurologic damage to progress. However, advise women who have had a previous neural tube defect-affected pregnancy to consult with their clinicians several months before planning to become pregnant about consuming a higher dose of folic acid. Public health measures to fortify the US food supply with folic acid are currently being implemented.

7. For patients who are overweight, recommend a diet with fewer total calories from fat and a modest increase in physical activity. See chapter 57 for information on physical activity counseling. In general, the goal should be a weight loss of ¹ / 2 to 1 pound per week. Although more rapid weight loss may be achieved with a very-low-calorie (800 kcal/day or less) diet, weight loss from these diets usually is not well maintained, and such diets may lead to health problems. Selected patients who have failed at conservative methods of weight loss and who are severely obese or have obesity-related medical problems may benefit from the short-term weight loss associated with very-low-calorie diets or from prescription weight loss medications, under medical supervision. Behavior therapy and physical activity have been shown to help maintain weight loss.

8. The National Cholesterol Education Program (NCEP) recommends that primary care providers instruct patients with borderline or elevated cholesterol levels in the use of a cholesterol-lowering diet. The Step I diet recommended by the NCEP has less than 300 mg per day of cholesterol and derives only 8% to 10% of total calories from saturated fatty acids. The Step II diet is recommended for patients whose cholesterol levels are not adequately reduced by the Step I diet. The Step II diet has less than 200 mg of cholesterol per day and derives less than 7% of total calories from saturated fatty acids. Referral to a dietitian is recommended for patients in need of the Step II diet. See Table 56.3 for examples of foods to choose for the Step I or Step II diet.

9. Provide ongoing support and reinforcement to patients undertaking significant dietary changes. This support can take several forms, including follow-up visits, telephone calls, and postcards. Recommend making changes gradually, in small, achievable steps over time. Encourage patients through the plateaus and regressions that occur as a normal part of efforts at long-term change.

10. Patients with multiple or severe nutritional problems should be referred, if possible, for counseling from a nutrition professional. Information on consulting registered nutrition professionals in the community can be obtained from the American Dietetic Association: (800)366-1655.

CHATS: A Guide to Sensible Eating (scripted slide show); Osteoporosis in Women: Keeping Your Bones Healthy and Strong. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Diet, Nutrition and Cancer Prevention: The Good News. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A24, Bethesda, MD 20892; (800)4-CANCER.

Eating Right To Lower Your Blood Cholesterol; Eating Right to Lower Your High Blood Pressure. National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222.

The Food Guide Pyramid; Nutrition and Your Health: Dietary Guidelines for Americans. 4th ed; Nutritive Value of Foods. Superintendent of Documents, US Government Printing Office, Washington, DC 20402; (202)783-3238.

Choosing a Safe and Successful Weight-Loss Program;/ Physical Activity and Weight Control; Prescription Medications for the Treatment of Obesity; Very Low Calorie Diets. The National Institute of Diabetes and Digestive and Kidney Disease, 1 WIN Way, Bethesda, MD 20892-3665; (800)946-8098.

Physician's Guide to Outpatient Nutrition. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Diet, Nutrition and Cancer Prevention: A Guide to Food Choices. Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A24, Bethesda, Maryland 20892; (800)4-CANCER.

Nutrition Screening Initiative. Educational material and office aids for screening elderly patients for nutritional deficiencies. Nutrition Screening Initiative, 1010 Wisconsin Ave NW, Suite 800, Washington, DC 20007; (202)625-1662.

Table 56.1. Determining Your Nutritional Health: Checklist for Older Adults *

Table 56.2. Optimal Calcium Requirements Recommended by the National Institutes of Health Consensus Panel

Table 56.3. Examples of Foods To Choose or Decrease for the NCEP Step I and Step II Diets *

In the last 25 years, the United States has seen a steady decline in age-adjusted deaths from cardiovascular disease (CVD). Despite this trend, cardiovascular disease continues to be the leading cause of death for Americans. Growing evidence indicates that physical inactivity is a major risk factor for CVD. In addition, physical inactivity is associated with other leading causes of disease and disability such as type 2 diabetes mellitus, colon cancer, obesity, osteoporosis, and falls.

Regular exercise reduces cardiovascular disease risk, promotes weight loss and control, improves musculoskeletal functioning, helps prevent diabetes, helps to control stress, and may help prevent bone loss associated with aging. Despite these advantages, physical activity levels among Americans are low. According to the 1996 Surgeon General's Report on Physical Activity and Health, more than 60% of Americans are not regularly physically active and 25% report no physical activity at all. The prevalence of physical inactivity is higher among women than men, among African Americans and Hispanics than Caucasians, among older than younger adults, and among the less affluent than the more affluent.

The relationship of physical activity to chronic health problems and the high prevalence of physical inactivity in the American population makes physical activity counseling an important role for clinicians. Surveys of primary care clinicians indicate that only about 30% routinely provide counseling on physical activity to their sedentary patients. Clinicians may consider referring patients to an exercise physiologist or a rehabilitation specialist for evaluation and in-depth counseling.

See chapter 21 for information on physical activity counseling for children and adolescents.

American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and the US Preventive Services Task Force (USPSTF) --

Providers should routinely assess patients' physical activity practices and counsel them in engaging in a program of regular physical activity that is tailored to their health status and lifestyle. USPSTF recommends that women receive counseling regarding the use of weight-bearing exercise to help prevent postmenopausal osteoporosis. Both the USPSTF and Canadian Task Force on the Periodic Health Examination state that the effectiveness of clinician counseling to promote increased patient physical activity is not established.

The National Institutes of Health Consensus Panel on Physical Activity and Cardiovascular Health --

All Americans should engage in regular physical activity at a level appropriate to their capacity, needs, and interest. Children and adults should set a goal of accumulating at least 30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week.

Weight Control: Losing Weight and Keeping It Off. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Women and Exercise (educational bulletin 173); Exercise and Fitness: A Guide for Women. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Weight Control: Eating Right and Keeping Fit (AP064; 50/pack). American College of Obstetricians and Gynecologists. (800)762-2264. Internet address: http://www.acog.com

Check Your Healthy Heart IQ; Check Your Physical Activity and Heart Disease IQ; Exercise and Your Heart; Aprenda a Reconocer un Corazon Sano. National Heart, Lung, and Blood Institute Smoking Education Program, PO Box 30105, Bethesda, Md 20824-0105; (301)251-1222 (English and Spanish). Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Anabolic Steroids and Athletes. American College of Sports Medicine, PO Box 1440, Indianapolis, IN 46206-1440; (317)637-9200. Internet address: http://www.acsm.org/sportsmed

The Physician's Rx: Exercise. President's Council on Physical Fitness and Sports, 701 Pennsylvania Ave, NW, Suite 250, Washington, DC 20004; (202)272-3421.

Physician-based Assessment and Counseling for Exercise. Project PACE, San Diego State University, San Diego, CA 92182-0567; (619)594-5949.

Table 57.1. Heart Rates (Beats/Minute) According to Age ***

Table 57.2. Overcoming Barriers to Exercise

Polypharmacy, the prescribing of multiple drugs for an individual patient, is most common in older adults, who tend to have more illnesses for which medications are prescribed. Adults aged 65 years and older represent 12% of the population but consume 30% of all prescription medications. Among persons older than age 65 years, the rate of nonprescription (over-the-counter) drug use is seven times that of the general population. The incidence of adverse drug reactions increases with advancing age and the number of drugs taken. Deteriorating vision and cognitive function cause older adults to make many mistakes when taking medications, often with serious consequences. Up to 10% of all hospital admissions for patients over 65 years of age involve medication toxicity.

Clinicians contribute significantly to the problem if they prescribe medications without considering changes in drug metabolism that occur with aging. Renal and hepatic function decrease with advancing age, slowing the clearance of medications. Increases in the proportion of body fat and decreases in the proportion of body water that occur with aging lead to an accumulation of fat-soluble medications in adipose tissue and increases in the concentration of hydrophilic medications in the blood.

Polypharmacy can occur in younger patients as well. As the number of symptoms and diseases increases in an individual, so does the risk of polypharmacy and the attendant risk of overmedication and adverse effects.

American College of Obstetricians and Gynecologists --

Clinicians should assess the use of prescription and nonprescription medications by women 65 years of age and older at each periodic health evaluation (annually or as appropriate).

American Nurses Association --

Clinicians should maintain a drug profile on older adults to evaluate/monitor for unnecessary and excessive drug use.

Age Page Medicines -- Use Them Safely; Age Page -- Safe Use of Tranquilizers by Older People. National Institute on Aging, Bldg 31, Room 5C27, 31 Center Dr MSC 2922, Bethesda, MD 20892-2922; (301)496-1752. Internet address: http://www.nih.gov/nia/health/pubpub/pubpub.htm

Patient Counseling Handbook. American Pharmaceutical Association, 2215 Constitution Ave NW, Washington, DC 20037, (202)628-4410, (800)878-0729.

FDA Ensures Equivalence of Generic Drugs; FDA Guide to Non Prescription Pain Relievers; FDA Guide to Choosing Medical Treatments; FDA's Tips for Taking Medicines. FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

National Council on Patient Education has forms available for providers to distribute to patients to assist with management of prescription medications. Phone: (202)347-6711; fax: (202)638-0773.

Table 58.1. How To Simplify the Medication Regimen

Almost 12 million cases of sexually transmitted diseases (STDs) occur annually in the United States. Eighty-six percent of such cases occur in persons aged 15 through 29 years. In addition to syphilis and gonorrhea, the list of STDs now includes human immunodeficiency virus (HIV) infection, Chlamydia trachomatis infection, genital herpes virus infection, human papilloma virus (HPV) infection, chancroid, genital mycoplasmas, cytomegalovirus infection, hepatitis B infection, vaginitis, enteric infections, and ectoparasitic diseases. Chlamydial infection is the most common STD, causing an estimated 4 million acute cases annually. Although the incidence of gonorrhea and syphilis decreased in the early 1990s, these diseases remain a persistent public health problem.

Acquired immunodeficiency syndrome (AIDS) is the eighth leading cause of death in the United States. It is now the leading cause of death among men aged 25 to 44 years and the third leading cause of death among women of the same age group. AIDS is the sixth leading cause of years of potential life lost in the United States. The Centers for Disease Control and Prevention estimate that 650,000 to 900,000 people in the United States are infected with HIV. No cure for AIDS currently exists, although treatment can delay onset of symptoms.

The consequences of STDs are particularly troublesome for women and children. Apart from AIDS, the most serious complications of STDs for women are pelvic inflammatory disease (PID), an increased risk of cervical cancer, ectopic pregnancy, congenital infection and malformations, delivery of premature and low-birth-weight infants, and fetal death. Persons who are poor or medically underserved and racial and ethnic minorities also contract a disproportionate number of STDs and the disabilities associated with them.

Individuals who are at increased risk for STDs and HIV infection include: (1) those who are or were recently sexually active, especially persons with multiple sexual partners; (2) those who use alcohol or illicit drugs; (3) gay or bisexual men who have sex with other men; (4) persons with a previous history of a documented STD/HIV infection and their close contacts; (5) persons involved in the exchange of sex for drugs or money; and (6) persons living in areas where the prevalence of HIV infection and STDs is high.

Many sexually transmitted diseases (AIDS, chancroid; Chlamydia trachomatis [genital infections only]; gonorrhea; hepatitis B; hepatitis C/non-A, non-B; HIV infection [pediatric cases only]; and syphilis) are currently designated as infectious diseases notifiable at the national level. Refer to Appendix C for further information on nationally notifiable diseases.

See chapter 40 for information on screening for STDs and HIV infection, chapter 23 for information on counseling children and adolescents about STDs and HIV infection, and chapters 25 and 61 for information about counseling to prevent unintended pregnancy among adolescents and adults, respectively.

American Academy of Family Physicians --

Adolescents and adults should be counseled about the risks for sexually transmitted diseases and how to prevent them.

American College of Obstetricians and Gynecologists (ACOG) and American College of Physicians --

Patients should be counseled on measures to prevent STDs and HIV infection. ACOG recommends offering HIV counseling and testing to all pregnant women and strongly encourages it for high-risk women. HIV and STD counseling should be included for all women as a part of their routine preventive services whether pregnant or not.

The Canadian Task Force on the Periodic Health Examination --

There is insufficient evidence to recommend for or against the inclusion or exclusion of the following from the periodic health examination of asymptomatic individuals: obtaining a history of sexual practices and injection drug use or counseling on high-risk sexual practices and condom use. There is fair evidence to include counseling to prevent the spread of gonorrhea.

Centers for Disease Control and Prevention --

Latex condoms should be made more widely available by health care providers in STD, family planning, and drug treatment clinics. HIV seronegative pregnant women and women of childbearing age who are at increased risk of becoming infected with HIV should receive additional counseling regarding the maternal and fetal risks associated with pregnancy should they become infected. STD and HIV screening should be offered to high-risk individuals; counselors should take advantage of all available opportunities to provide patients with HIV-prevention messages. HIV pretest counseling must include a personalized patient-risk assessment and should result in a personalized plan for the patient to reduce the risk of HIV infection.

US Preventive Services Task Force (USPSTF) --

All adolescent and adult patients should be advised about risk factors for sexually transmitted diseases and HIV infection and counseled appropriately about effective measures to reduce risk of infection. This recommendation is based on the proven efficacy of risk reduction, although the effectiveness of clinician counseling in the primary care setting is uncertain. Counseling should be tailored to the individual risk factors, needs, and abilities of each patient. Assessment of risk should be based on a careful sexual and drug use history and consideration of the local epidemiology of STDs and HIV infection. Patients at risk of STDs and HIV infection should receive information on their risk and be advised about measures to reduce their risk. Effective measures include abstaining from sex, maintaining a mutually faithful monogamous sexual relationship with a partner known to be uninfected, regular use of latex condoms, and avoiding sexual contact with high-risk individuals (eg, injection drug users, commercial sex workers, and persons with numerous sex partners). Women at risk of STDs should be advised of options to reduce their risk in situations when their male partner does not use a condom, including the female condom. Warnings should be provided that using alcohol and drugs can increase high-risk sexual behavior. Persons who inject drugs should be referred to available drug treatment facilities, warned against sharing drug equipment and, where possible, referred to sources for uncontaminated injection equipment and condoms. All patients at risk for STDs should be offered testing in accordance with USPSTF recommendations for screening for syphilis, gonorrhea, chlamydia, genital herpes, hepatitis B, and HIV infection (chapter 40).

How to Prevent Sexually Transmitted Diseases, Genital Herpes, Gonorrhea and Chlamydia, Pelvic Inflammatory Disease. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

HIV Infection and Women. ACOG Patient Education Pamphlet AP082. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Giving and Receiving Blood (#329 546); Testing for HIV Infection (#329 547); Women, Sex, and HIV (#329 537); HIV Infections and AIDS (#329 560). Available through your local chapter of the American Red Cross.

Surgeon General's Report to the American Public on HIV Infection and AIDS; Condoms and Sexually Transmitted Diseases ... Especially AIDS. To order these and many other materials, contact the CDC National AIDS Information Hot Line: (800)342-AIDS (English speaking); (800)344-SIDA (Spanish speaking); (800)AIDS-TTY (hearing impaired). All phone calls are confidential.

HIV in America: A Profile of the Challenges Facing Americans Living With HIV. National Association of People Living with AIDS, 1413 K St, NW, Washington, DC 20005; (202)898-0435.

National STD Hot Line: (800)227-8922; (809)765-1010 (Spanish; call collect).

Information on hemophilia and HIV: Hemophilia and AIDS Network for the Dissemination of Information, 110 Green St, New York, NY 10012; (800)424-2634.

Women, AIDS, and Drug Use Annotated Client Education Directory. NOVA Research Co, 4600 East-West Hwy, Suite 700, Bethesda, MD 20814; (301)986-1891.

National AIDS Information Hotline, Centers for Disease Control and Prevention, (800)342-AIDS.

HIV Infection and AIDS (monograph); HIV Infection in the Family Physician's Office (brochure); Clinical and Psychosocial Aspects of Caring for HIV Patients (audiotape); HIV Infection and Physician Emotions (videotape and discussion guide). American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Gynecologic Herpes Simplex Virus Infection (technical bulletin 119). American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

National AIDS Information Clearinghouse. PO Box 6003, Rockville, MD 20850; (800)458-5231. General information (in both English and Spanish) on STDS, HIV, AIDS and AIDS-related diseases (seven brochures) and fact sheet packet (10 brochures).

National HIV Telephone Consultation Service is a clinical consultation service of health care providers: (800)933-3413.

National AIDS Information Hotline, Centers for Disease Control and Prevention, (800)342-AIDS.

Table 59.1. Examples of Questions for Taking Clinical Histories About Sexual Behavior

More than 400,000 people die of tobacco-related causes annually. Cigarette smoking is the leading cause of preventable death in the United States, and smoking cessation is a critically important topic for patient counseling because of its potential benefit. Figure 60.1 shows the benefits of smoking cessation for different parts of the smoker's body. Evidence also suggests that nonsmokers who are exposed to environmental tobacco smoke are susceptible to lung cancer and possibly coronary heart disease. Rates of chronic middle ear effusions, pneumonia, and asthma are increased among children who are exposed to environmental tobacco smoke.

Primary care clinicians can play a key role in helping patients quit smoking. Even very simple interventions by clinicians can lead to long-term quit rates of 5% to 10%. More extensive interventions, including use of nicotine gum and patches, can lead to quit rates that are significantly higher. If all primary care providers used simple interventions such as asking about smoking status and suggesting that patients quit smoking, the national smoking cessation rate could double. Recent studies indicate, however, that fewer than half of patients who smoke receive any assistance in quitting from their health care providers.

See chapter 24 for information on counseling children and adolescents on prevention of tobacco use. See chapters 19 and 54 for information about counseling on dental and oral health for children and adolescents and for adults, respectively. See chapters 18 and 53 for information about counseling on alcohol and other drug abuse for children and adolescents and for adults, respectively.

All major authorities, including the American Academy of Family Physicians (AAFP), American Cancer Society, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, Canadian Task Force on the Periodic Health Examination, National Heart, Lung, and Blood Institute, National Institute of Dental Research, and US Preventive Services Task Force, and the Smoking Cessation Guideline Panel convened by the Agency for Health Care Policy and Research and the Centers for Disease Control and Prevention --

For patients who smoke, clinicians should provide smoking cessation counseling, consider drug therapy with nicotine products, and referral as appropriate to smoking cessation programs. The AAFP recommends counseling be done on a regular basis to smokers, as multiple messages are often needed, and the harmful effect of smoking on children's health be emphasized to smoking parents.

Several major authorities, including Joint Commission on Accreditation of Health Care Organizations --

Smoking should be prohibited in health-care facilities.

• Select a date for the office to become smoke-free. Advise all staff and patients of this plan.
• Post no-smoking signs in all office areas.
• Remove ashtrays.
• Display nonsmoking materials and cessation information prominently.
• Do not use waiting room magazines that contain tobacco advertising. A list of such magazines is available (Glynn and Manley, 1995; Goldsmith, 1991).

Smoking: Steps To Help You Break the Habit. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000; Internet address: http://www.aafp.org

How to Quit Cigarettes; The Fifty Most Often Asked Questions about Smoking and Health and the Answers. To order these and other materials, contact your local office of the American Cancer Society or call (800)ACS-2345.

Smoking in Women. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Smoking Can Really Do a Number on Your Health. To order this and other material, contact the American Dental Association, Department of Salable Materials, 211 E Chicago Ave, Chicago, IL 60611; (800)947-4746.

Chew or Snuff Is Real Bad Stuff; Why Do You Smoke? National Cancer Institute. Superintendent of Documents, Consumer Information Center 3C, PO Box 100, Pueblo, CO 81002.

Check Your Smoking I.Q.: An Important Quiz for Older Smokers. To order this and other material, contact the National Heart, Lung, and Blood Institute Smoking Education Program, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish); Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

You Can Quit Smoking: Smoking Cessation Consumer Guide, Clinical Practice Guideline Number 18. Publication number 96-0695. Call or write: Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring MD 20907; 1-800-358-9295, Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions); Internet address: http://www.ahcpr.gov

Stop Smoking Kit. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000; Internet address: http://www.aafp.org

Smoking and Reproductive Health. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Technical Bulletin AT180.

Doctors Helping Smokers. To order this office-based tobacco cessation program and video by the same name, contact Doctors Helping Smokers at Blue Plus, PO Box 64179 R 3-11, St. Paul, MN 55164; (800)382-2000, ext 1975.

How To Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians; How To Help Your Patients Stop Using Tobacco: A National Cancer Institute Manual for the Oral Health Team. To order these and other materials, contact the Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER; Internet address: http://cancernet.nci.nih.gov

Helping Smokers Quit: A Guide for Primary Care Clinicians, Clinical Practice Guideline No. 18, AHCPR Publication No. 96-0693. Call or write: Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; (800)358-9295, Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions); Internet address: http://www.ahcpr.gov

Nurses: Help Your Patients Stop Smoking. National Heart, Lung, and Blood Institute Smoking Education Program, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish); Internet access: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Table 60.1. Smoking Assessment Form

Table 60.2. Availability of Pharmacologic Agents for Smoking Cessation

Table 60.3. Information About Nicotine Patch Use

Table 60.4. Information About Nicotine Gum Use

Table 60.5. Information About Nicotrol Inhaler Use

Table 60.6. Information About Nicotrol Nasal Spray (Nicotrol NS) Use

Table 60.7. Information About Use of ZybanTM (Bupropion Hydrochloride) Sustained-Release Tablets

From: Centers for Disease Control, Office on Smoking and Health. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, At a Glance, 1990. Rockville, Md: Centers for Disease Control; 1990. USDHHS publication CDC 90-8419.

Modern contraceptives have enabled women to increase control over their reproductive lives. However, in the United States 60% of all pregnancies are unintended. Unplanned pregnancies affect women of all ages and circumstances; however, their number is higher in certain population groups, such as teenagers (82% of pregnancies unintended) and never-married women (88% of pregnancies unintended). The consequences of these pregnancies in the United States include approximately 1.5 million abortions annually, children who are at increased risk of health and behavior problems in childhood and later in life, and pregnancies that have not benefitted from preconception risk identification and management.

Screening, counseling, and preventive services are particularly needed for older women of childbearing age. For women aged 35 to 39, 56% of pregnancies are unintended. For women aged 40 to 44, the number is 77%, and 59% of these end in abortion, the highest percentage for any age group from age 15 to 44. Pregnancies of women aged 40 to 44 and beyond, while small in absolute numbers, are disproportionately unintended, likely to end in abortion, and likely to entail other adverse outcomes. The large percentage of unintended pregnancies for women approaching age 44 suggests that both women and their care givers underestimate the potential for, and fall short of, adequate protection against pregnancy during these years when fertility is expected to decline.

Modern contraceptives marketed in the United States have been shown to be safe and effective (Table 61.1). Although most are relatively inexpensive, their costs vary.

See chapter 25 for information on counseling to prevent unintended pregnancy in adolescents. See chapters 23 and 59 for information on counseling to prevent sexually transmitted diseases and HIV infection among adolescents and adults, respectively.

American College of Obstetricians and Gynecologists and US Preventive Services Task Force

Primary care providers should obtain a history of sexual practices and provide counseling on the prevention of unintended pregnancy and contraceptive options to all sexually active women who do not want to become pregnant and men who do not want to have a child. Counseling should also be provided regarding high-risk sexual behavior and the prevention of STDs and HIV infection.

1. The main goal is to make sure family planning is a part of primary care for all sexually active patients. Assess sexual practices and the need for contraceptive counseling for every patient, including women in their forties and men. This can be done as a part of periodic health examinations or during acute care visits for issues of a related nature, such as STDs, postpartum care, or family stress. As with all counseling of patients regarding sensitive topics, address this issue with openness and a nonjudgmental attitude.

2. Determine each patient's level of knowledge about contraceptive options. What methods have they tried in the past? Have these methods been acceptable and effective for the patient and partner or partners? What medical and life-style factors could influence the patient's choice of an appropriate contraceptive?

3. Educate patients about the important characteristics of different contraceptive methods (Table 61.2). Present the patient with a range of contraceptive options. Assist patients in carefully choosing a contraceptive method that is appropriate for their abilities, motivation, and life-style, thereby increasing the likelihood that it will be used correctly and consistently. Encourage patients who are already using a method correctly and successfully to continue to do so.

4. Discuss the ability of different contraceptive methods to protect against sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) infection. Latex condoms, used consistently and correctly, are effective for both birth control and reducing the risk of disease. Other forms of birth control, such as IUDs, diaphragms, cervical caps, and oral contraceptives, do not give the same protection. Stress to patients that even if they use another form of birth control, if they are not involved in a mutually monogamous relationship with a person known to be free of infection, they also need to use condoms to reduce the risk of STDs.

5. Contraception is a responsibility of both partners. If possible, involve both partners in counseling and discussion of contraceptive options. See Table 61.1 for an evaluation of the effectiveness of various contraceptive methods. Also discuss ways in which males can participate in family planning.

6. After patients choose a method, conduct an in-depth discussion of:

• How it works
• Theoretical and actual effectiveness
• Advantages/benefits
• Disadvantages/risks
• How to use the method
• Nuisance side effects
• Warning signs
• Back-up methods.

Provide patients with printed material about the contraceptive method chosen (Patient Resources).

7. Follow-up counseling is particularly important in the first few weeks of contraceptive use to deal with any difficulties associated with use and side effects. Ask patients how they are using the method, correct misinformation, and discuss any impediments to proper use of the method. Continue counseling during each patient visit, especially until patients are very comfortable with use of the contraceptive method. Many compliance problems can be resolved relatively simply with reassurance and changes in dose or technique of use.

8. Oral contraceptives (OCs) can also be prescribed as a postcoital ("morning after") method to prevent pregnancy (Table 61.3). The Food and Drug Administration announced in February 1997 that certain combined oral contraceptives containing ethinyl estradiol and norgestrel or levonorgestrel were safe and effective for use as postcoital emergency contraception . This approach to emergency contraception has been reported to reduce the risk of pregnancy by 55.3% to 94.2% after unprotected intercourse if treatment is initiated within 72 hours.

Instruct the patient to take the first dose as soon as possible (but no more than 72 hours) after unprotected intercourse; the second dose is taken 12 hours after the first dose. The most common side effects of these regimens are nausea and vomiting.

Birth Control: Choosing the Method That's Right for You. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org

Barrier Methods of Contraception; Contraception (in English and Spanish); Family Planning by Periodic Abstinence; The Intrauterine Device; Oral Contraceptives; Postpartum Sterilization; Sterilization by Laparoscopy; Sterilization for Women and Men. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Drugs and Pregnancy: Often the Two Don't Mix; Choosing a Contraceptive. FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.

Emergency Contraception Website. The Office of Population Research at Princeton University. Internet address: http://opr.princeton.edu//ec/hotline.html

Emergency Contraception Hotline. The Office of Population Research at Princeton University. (800)584-9911.

Facts About Birth Control. Planned Parenthood, 810 7th Ave, New York, NY 10019; (212)541-7800; Internet address: http://www.igc.org/ppfa

Hormonal Contraception. (ACOG Educational Bulletin #198). American College of Obstetricians and Gynecologists. 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Emergency Contraception. (ACOG Practice Pattern #3). American College of Obstetricians and Gynecologists. 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Food and Drug Administration. Prescription Drug Products; Certain Combined Oral contraceptives for Use as Postcoital Emergency Contraception; Notice. Federal Register. 1997; 62(37)8610-8612.

The Intrauterine Device (technical bulletin 164). American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

Managing Contraceptive Pill Patients. EMIS Publishers, Dallas, TX; (800)225-0694.

Oral Contraceptive User Guide (Second Edition). EMIS Publishers, Dallas, TX. (800)225-0694.

Planned Parenthood. Planned Parenthood at 810 7th Ave, New York, NY 10019; (212)541-7800. Internet address: http://www.igc.org/ppfa

Table 61.1. Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year, United States.

Table 61.2. Complications, Side Effects, and Benefits of Major Methods of Contraception

Table 61.3. Oral Contraceptives for Use as Postcoital Emergency Contraception

According to the National Osteoporosis Foundation, more than 25 million Americans have osteoporosis, and each year more than 1.3 million fractures occur as a result. Osteoporosis is the most common metabolic bone disorder, and the risk for osteoporosis and osteoporosis-related fractures increases with advancing age. As the population of the United States ages, osteoporosis becomes an increasing public health concern.

About 70% of fractures in persons aged 45 or older are related to osteoporosis. The earliest and most predominant fractures involve the lower thoracic and lumbar vertebrae. These are often asymptomatic and may be diagnosed through spinal x-rays obtained for other reasons. These fractures produce loss of height and the development of a "dowager's hump," a distortion of the spine. As these fractures progress, they produce compression of the abdominal cavity, resulting in difficulties eating and digesting. After age 65, fractures of the hip and of the arm produce greater morbidity and are associated with pain, disability, and decreased functional ability. In the first year following a hip fracture, a patient's expected survival decreases 15% to 20%. The economic impact of osteoporosis is also high. In 1995, an estimated $13.8 billion was spent in the United States for osteoporosis-related medical, nursing home, and social costs. These numbers are expected to increase over the next 20 years.

Important risk factors for osteoporosis are female gender, low dietary intakes of calcium during adolescence, age, and early menopause. Women of Caucasian or Asian ancestry and those whose mothers have had osteoporosis are at greatest risk. Dietary intake of calcium during childhood and adolescence is a determinant of adult peak bone mass. Peak bone mass is achieved in the third decade, after which bone loss begins. In women, bone loss is accelerated by menopause, particularly premature menopause induced by oophorectomy. Low body weight, excessive alcohol intake, and sedentary life style have been associated with osteoporosis as well. Parity, lactation history, caffeine intake, and smoking have been suggested in the past as possible risk factors but are poor predictors of bone mass.

The main techniques available for screening for osteoporosis include single photon absorption (SPA), dual photon absorption (DPA), dual energy x-ray absorption (DXA), and quantitative computed tomography (QCT). DXA is currently the favored method because of its ease of use, good precision, relatively low procedure time (5 to 10 minutes), and very low radiation dose. Like the SPA and DPA, however, it cannot discriminate between cortical bone and trabecular bone; QCT must be used to accomplish this. DXA measures bone mineral content (g/cm) or areal density (g/cm²) and may be used over the total body or for a specific area. Most experts agree that DXA is a safe, accurate, and precise modality for measuring bone density. Ultrasound technology for assessing bone density is under development and may be of use in the future.

DXA can identify at risk persons who can most benefit from interventions; however, because the rate of postmenopausal bone loss varies among women, bone mass at menopause correlates only moderately with bone mass 10 to 20 years later when most fractures occur. Also, no consensus exists regarding what interventions are indicated for patients with any particular level of bone density.

See chapter 47 for information on hormone replacement therapy. See Chapter 56 for information on nutrition counseling and Chapter 57 for information on physical activity counseling.

American Academy of Family Physicians --

All patients should be counseled about the importance of adequate calcium intake, regular weight-bearing exercise, smoking cessation, and moderate alcohol use. Patients at risk and those diagnosed with osteoporosis should be advised of treatment options. Bone densitometry cannot be recommended for routine use at this time. Bone mineral densitometry may be useful for high-risk patients, to monitor therapy, and for patients who are unable to come to a decision about hormone replacement therapy.

American College of Obstetricians and Gynecologists --

All women should be counseled on diet and exercise as part of routine preventive visits. Women over 40 should be counseled on use of hormone replacement therapy. Women 65 and over should be counseled on fall prevention.

American College of Physicians --

Routine screening of all postmenopausal women by bone densitometry for osteoporosis is not recommended. Bone density measurements may be indicated in specific clinical situations where the decision to treat must be based on knowledge of bone mass and related to risk of fracture.

Canadian Task Force on Periodic Health Examination --

Does not recommend routine radiologic screening for osteoporosis. Bone density measurements may be useful to guide treatment in selected postmenopausal women considering hormone replacement therapy. The CTFPHE recommends counseling all peri-menopausal women regarding the benefits and risks of estrogen replacement therapy; however, there is insufficient evidence to recommend for or against the inclusion or exclusion of counseling premenopausal and postmenopausal women to engage in regular weight-bearing exercise to reduce osteoporosis risk.

National Osteoporosis Foundation --

Recommends a comprehensive program to prevent osteoporosis in women and men of all ages that includes adequate calcium and vitamin D intake, weight-bearing exercises, a healthy lifestyle with no smoking and limited alcohol consumption, and medication when appropriate. A bone mineral density (BMD) test is the only way to detect bone loss before a fracture occurs. A BMD test is indicated when risk factors are present and a decision must be made regarding osteoporosis medications to reduce fracture risk.

National Institutes of Health --

A 1984 consensus conference on osteoporosis recommended that estrogen therapy after menopause should be considered in high-risk women who have no medical contraindications and who are willing to adhere to a program of careful follow-up.

US Preventive Services Task Force --

There is insufficient evidence to recommend for or against routine screening for osteoporosis with bone densitometry in postmenopausal women. Recommendations against routine screening may be made on other grounds. All postmenopausal women should be counseled about hormone prophylaxis and advised of the importance of smoking cessation, regular exercise and adequate calcium intake. For those high-risk women who would consider estrogen only to prevent osteoporosis, screening may be appropriate to assist treatment decisions.

World Health Organization --

Bone density measurements may be useful to guide treatment in selected postmenopausal women considering hormone replacement therapy.

The most effective management for osteoporosis is the prevention of osteoporosis through counseling about dietary and behavioral practices to maximize the peak bone mass achieved by the third decade and to slow the rate of bone loss after that period.

Recent studies have shown that women who start HRT late after menopause receive the same protective effect against risk of subsequent fractures as those who start treatment during or immediately after menopause. Counsel each patient about the risks and benefits of hormone replacement therapy (chapter 47).

This third-generation amino-bisphosphonate that acts as an osteoclast inhibitor, has been approved for the prevention and treatment of osteoporosis. Initial studies have shown that alendronate not only arrests further loss of bone mineral content, but in many cases leads to an actual increase in bone mineral density. Alendronate treatment is also associated with decreases in fractures in people with low bone mass density who have already had a spine fracture. Other bisphosphonate agents are currently under review, and these agents may increase treatment options for patients.

Calcitonin, a hormone that helps control bone remodeling, is administered by injection (subcutaneously or intramuscularly) or by nasal spray. Side effects include flushing, rash, nausea, dizziness, and faintness. Calcitonin does not offer the other benefits of estrogen (control of hot flashes, lowering of cholesterol, protection against coronary heart disease), and its efficacy in fracture prevention has not been proven. Its effectiveness has been demonstrated only in women with established osteoporosis who are more than 5 years postmenopausal.

Osteoporosis in Women: Keeping Your Bones Healthy and Strong. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City MO 64114-2797; (800)944-0000.

Preventing Osteoporosis (ACOG Patient Education Pamphlet AP048). American College of Obstetricians and Gynecologists. 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com

National Osteoporosis Foundation, Osteoporosis and Related Bone Disorders National Resource Center, 1150 17th St, NW, Suite 500, Washington, DC 20036; (800)624-BONE.

National Osteoporosis Foundation, Osteoporosis and Related Bone Disorders National Resource Center, 1150 17th St, NW, Suite 500, Washington, DC 20036; (800)624-BONE.

Table 62.1 Risk Factors for Hip Fractures