PICOT; Literature Review

PICOT; Literature Review


Upon the realization of the devastating effects of chronic diseases among the aged population in the United States, it has become a common goal for the American Cancer Society (ACS), The American Heart Association (AHA) and the American Diabetes Association to detect and treat the chronic diseases early. I total, cancer, cardiovascular diseases like stroke and diabetes mellitus are responsible for approximately two-thirds of all the deaths in the United States. Also, the conditions combined have cost the country’s economy nearly 700 billion dollars either directly or indirectly. As things are, the effort put on the current knowledge is inadequate (Gaugler, 2015). There needs to be more public health involvement in reducing the habits and lifestyles that increase the risk of people getting these chronic diseases in their adulthood.

Burden of Diseases

People in America need to start utilizing the screening tests early enough so that that they can detect the chronic diseases early enough. Such a trend in this country would significantly reduce the human and the economic cost levied by the conditions of the American people. There needs to more effort on primary prevention if the older population is to be saved from their most common ailments. Diabetes mellitus, cancer, and cardiovascular diseases are responsible for the death of two out of every three American aged 65 years or more. These chronic diseases bring untold suffering, disability, and economic cost not only to the older adults but also to their families and friends (Hung, Ross, Boockvar & Siu, 2011). It is disturbing to know that these are diseases whose onset and progress could be prevented had certain measures been taken.

It is possible to reduce the premature mortality and the disability of aged persons if only the underlying causes of cardiovascular diseases, cancers and diabetes mellitus are detected and treated early when the treatment interventions are most effective. Despite the overwhelming evidence, the current efforts to prevent disease has been underwhelming. The funds channeled towards prevention are a stark contrast to what the rest of health care is getting. As the country hopes for a change in the approach of the health care delivery with the enactment of the Affordable Care Act (ACA), the effort put now is still inadequate.  A report compiled by the National Center for Health Statistics (NCHS) has recently revealed that too many middle-aged Americans are still physically inactive, smoking cigarettes and are overweight (Hung, Ross, Boockvar & Siu, 2011); all of which are the primary precursors for cancer, diabetes mellitus and cardiovascular diseases such as stroke, high blood pressure and heart failure.

Trends and statistics of the disease

The U.S. Preventive Services Task Force (USPSTF) regularly conducts a review of the services offered in the preventive care settings. The USPSTF currently recommends that average Aged Americans start going for routine breast, cervical, colorectal prostate cancer screening. The Task Force further recommends screening for hyperlipidemia, hypertension, and blood sugar levels for young people so that any abnormalities can be detected early enough, treated or managed by the preventive medicine (Gaugler, 2015). Similarly, the Center for Disease Control (CDC) recommends that screening for cancer, cardiovascular disease, and diabetes mellitus should start early to reduce the burden of chronic diseases in the aged population in America.

It is not solely the responsibility of the public sector in the Department of Health and Human Services (DHHS), it is also a task that the private nonprofit organizations can collaboratively participate. To achieve the goals of Healthy people 2020, the industry has to provide a linkage between the state and federal governments, between the insurers, policy makers the public and the professional associations.  The health care provider and the medical organizations ought to change the system to one that focuses on providing preventive care are the integral component of medicine and as a standard of medical and nursing practice in this country (Nicholas & Hall, 2011).

Important to note is the fact that the trends in the prevalence, incidence, and mortality rated of the chronic diseases in America are significantly influenced by the changes in the prevalence of the risk factor, trends in treatment, utilization of screening services and the demographic shifts in the population of Americans (Hung, Ross, Boockvar & Siu, 2011).

The aging and the increase in the population is of particular importance now because of the associative relationship between aging and the chronic diseases. Unless there are more testing and screening of middle-aged Americans for cancer, CVD and DM the prevalence of these chronic diseases among the aged should be expected to continue rising. We could take a leaf from past successes in health care due to an emphasis on primary prevention. The death rates related to stroke and coronary artery diseases declined significantly from the 1940’s to the 1960’s due to more efforts put in primary prevention. Whereas the death rates due to CVD have decreased by approximately 17% over the last ten years, the number of fatalities a has risen steadily by 2.5% each year due to the increase in the size of the population aged above 65 years old (Hung, Ross, Boockvar & Siu, 2011).

Likewise, cancer has in the past experienced a decline in the mortality rates of the chronic disease. Over the period between 1991 and 2000, the death rate of cancer reduced by an average of 7.2%, it is important that one asks, why? The reduction was attributed to improvements made to early detection of the disease and treatment. Just as observed in the CVD, the prevalence of cancer deaths continues to rise annually due to the increase in the aging population (Gaugler, 2015). Diabetes is no different to the first two; there is an increase in the prevalence and mortality rates because there in not enough screening and other preventive measures taking place by the young people when they have time to go from regular checking (Nicholas & Hall, 2011). The end result is that they develop symptomatic diabetes at a late stage when treatment is difficult especially after complications to the other parts of the body have arisen.

Perhaps to encourage the fellow is the fact that diabetes mellitus, cancers and cardiovascular diseases share the majority of the risk factors. Increased age, family history, cigarette smoking, sedentary lifestyles, high blood sugar, hyperlipidemia and inadequate dietary intake are some of the risk factors that could predispose one to the chronic diseases. This reality presents an opportunity that can be exploited by the American people. Instead of having to go for different screening tests for each of the chronic diseases, one can go for a few that screens for all the chronic diseases. The older population will have saved on cost and will be aware of their health status early enough. All the disease can be treated or prevented more efficiently if the diagnosis is made early.

Because scientists have established that reducing the risk factors of the disease alone cannot eliminate the risk of getting cardiovascular diseases, early detection of the disease has the potential to alter the natural history of chronic diseases (Nicholas & Hall, 2011).  For diabetes, cancers and cardiovascular diseases, screening for the risk factors or the early signs and symptoms can lower the mortalities and incidences through the recommendations for changes in lifestyle, pharmacologic interventions and the treatment of precursor lesions or earlier treatment of the disease itself (Chentli, Azzoug & Mahgoun, 2015).


Cardiovascular diseases

Hypertension significantly increases the risk for cardiovascular diseases. Going for regular check up for the conditions is a good way of screening for the disease (Bibbins-Domingo et al., 2016).


For an extended period, studies have associated high levels of blood cholesterol with coronary artery disease. Despite the fact that older Americans have clear dietary outlines, almost a half of Americans still have total cholesterol greater than 200mg/dl. The problem is most prevalent among the aged population. Despite the fact that the screening for cholesterol levels has been on the steady rise, the awareness regarding the adverse effects of the LDL to the human body is low among the aged population.  Just as important is the fact that among the individuals who have met the criteria for treatment of high blood cholesterol among the older adults, less than half of them are getting the treatment or hyperlipidemia (Bibbins-Domingo et al., 2016). Worse still, older adults who have had lipid lowering drugs prescribed for them are not complying with their treatment. Here the attention must be focused on screening and compliance too.

Novel Predisposing Factors

There has been significant attention given to the additional factors that when assayed can provide more insight into the likelihood of one getting cardiovascular diseases.  Measurement of blood plasma homocysteine, more individual lipoprotein panels, imaging of vascular calcium and high sensitivity C-reactive protein are some of the new factors. All of these new markers have proven in studies that they can help in identifying where the risk of an individual lies (Bibbins-Domingo et al., 2016).

Early and global risk assessment

According to the American Heart Association, an adult at the age of 20 years should have their risk for cardiovascular disease assessed regularly. Additionally, because many factors determine the individual’s risk, the benefits of the interventions are dependent on the risk level, a global or multiple risk assessments is a better tool to guiding that person to the care that promises the most benefit and the most reduced risk. Currently, the Framingham risk score is the best available score.


Cancers that can be detected early by screening form approximately half of the new cases of cancer. The five-year relative rate of survival for these cancers is 84%.  If all these cancers had been diagnosed at a localized stage in their growth by regular screening, the survival rate would then increase to 95% (Rochman, 2014). All these serve to underline the importance of testing for the cancers at an early age to reduce the mortality rates related to cancer among the older adults.

Breast cancer

There have been encouraging results for breast cancer; RCTs conducted in Europe and the U.S. have made known the value of routine screening with mammography in reducing the mortality and the morbidity rates related to breast cancer among the aged population (Rochman, 2014).  Regular mammography has proven to be efficacious in reducing the deaths related to breast cancer among women aged between 40 and 69 years.  There is a mortality reduction of approximately 50% in at least half of the women who go for regular annual screening for breast cancer.

Recommendations from similar studies suggest that women should go for regular mammography by the time they attain the age o 40 years, after which they should ensure they have at least one mammography annually. According to the American Cancer Society, young women between the ages of 20 and 39 years should have clinical breast examinations every three years with annual tests starting after they attain the age of 40 years. Provided a woman is in good health and is a potential candidate for breast cancer, she should continue to have mammography (Rochman, 2014). A decision to stop should be based on the individual considerations of the likely benefits and risks of screening.

Cervical cancer

Screening here is recommended to begin three years after the onset of vaginal intercourse but should be no later than age 21. The testing should go annually until the age of 30 years if one prefers the conventional cervical cytology smears. For the liquid-based cytology, the woman can go once every two years until they reach the age of thirty.  Screening should become more intensive after the age of thirty. Human papillomavirus testing should also be conducted on the women after the age of thirty years (Rochman, 2014). Women after the age of 70 can stop going for cervical screening tests if they have had three consecutively successful screening tests.

Colorectal cancer

Adults at average risk should commence screening at the age of 50 years according to ACS. There around five tests from which these individuals can choose. The other adults with increased or higher risk levels should have more intense surveillance; such are those with a family history of colorectal cancers or personal records (Rochman, 2014).

Prostate cancer

An annual digital rectal examination (DRE) and a prostate-specific antigen (PSA) are recommended for men older than 50 years. For people who are at higher risk for the disease such as those with African sub-Saharan origin, testing should commence at the age of 40 years (Rochman, 2014).


Current studies suggest that the opportunistic screening to detect pre-diabetes state should be taken seriously for individuals aged 45 years and above, especially for those people with a BMI above 25Kg/m.  Screening should also be done for the people below 45 years but have other risk factors for diabetes such as hypertension, family history, and Dyslipidemia.  The Americans of Asian origin should also be considered at lower BMIs (23Kg/m)  (Chentli, Azzoug & Mahgoun, 2015).


In summary, the number of older Americans affected by the chronic diseases is increasingly worrying. Cancer, cardiovascular diseases and diabetes mellitus are slowly becoming a hallmark of older adulthood in America. It is important that these conditions are not perceived as normal at that age rather as preventable and avoidable. One proven way of preventing these chronic diseases is through regular annual screening that begins at an early age. The Early screening will promote chances of early detection of the disease at a stage where the medical interventions to treat the diseases are most effective. Emphasis should, therefore, be put on screening if we are to eliminate the human and economic cost of these chronic diseases on the older population in the U.S.




Bibbins-Domingo, K., Grossman, D., Curry, S., Davidson, K., Epling, J., & García, F. et al. (2016). Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. JAMA316(19), 1997. doi:10.1001/jama.2016.15450

Chentli, F., Azzoug, S., & Mahgoun, S. (2015). Diabetes mellitus in elderly. Indian Journal Of Endocrinology And Metabolism19(6), 744. doi:10.4103/2230-8210.167553

Gaugler, J. (2015). Chronic Disease and Aging. Journal Of Applied Gerontology34(3), 273-276. doi:10.1177/0733464815573392

Hung, W., Ross, J., Boockvar, K., & Siu, A. (2011). Recent trends in chronic disease, impairment and disability among older adults in the United States. BMC Geriatrics11(1). doi:10.1186/1471-2318-11-47

Nicholas, J. & Hall, W. (2011). Screening and Preventive Services for Older Adults. Mount Sinai Journal Of Medicine: A Journal Of Translational And Personalized Medicine78(4), 498-508. doi:10.1002/msj.20275

Rochman, S. (2014). Cancer Screening in Older Adults: Risks and Benefits. JNCI Journal Of The National Cancer Institute106(12), dju414-dju414. doi:10.1093/jnci/dju414