of periodic health examination and risk of mortality in a cohort of
elderly people in Taiwan
Tony Hsiu-Hsi CHEN3
and Jen-Pei LIU4
of Family Medicine, Cardinal Tien Hospital and 2-4Graduate
Institute of Preventive Medicine, College of Public Health, National
Taiwan University, Taiwan
Comprehensive periodic health examination of elderly people is popular
in Taiwan. The purpose of this study is to identify predictors of
mortality of the elderly from the findings of their periodic health
Methods: From the period 1996-1999, 4794 elderly people aged
65 and older underwent periodic health examination in our institution.
The status of survival of these 4794 subjects up to 31 December, 2000
was ascertained. Cox proportional hazard regression was performed
to estimate the hazard ratio of mortality of the findings in the health
Results: The median follow-up time was 34 months. In the multivariate
model, significant findings associated with increased mortality included:
smoking daily (hazard ratio [HR]: 1.401; 95% CI = 1.000-1.963); intake
less than three dishes of vegetables and two fruits per day (HR: 1.434;
95% CI = 1.049-1.960); urine protein > 0.3 g/L (HR: 2.184; 95%
CI = 1.399-3.411); low hemoglobin (HR: 1.924; 95% CI = 1.423-2.602);
serum albumin < 40 g/L (HR: 2.108; 95% CI = 1.514-2.935); globulin
> 35 g/L (HR: 1.421; 95% CI = 1.034-1.952); serum aspartate transaminase
level > 40 IU/L (HR:2.468, 95% CI = 1.571-3.878); and blood urea
nitrogen level > 7.8 mmol/L (HR: 1.427; 95% CI = 1.025-1.988).
Conclusions: Lifestyle, dietary habit and some findings of
the blood and urine tests done in the periodic health examination
were found to be significantly associated with the mortality of people
aged 65 years or older in Taiwan.
Key words: elderly, mortality, periodic health examination,
The demands and needs of the healthcare services of the elderly population
has increased rapidly in Taiwan. By the end of 2002 there were more than
2 million elderly people aged 65 years and older, approximately 9% of
the total population. The burden of illness is very high in this elderly
population. Periodic health examination has been widely promoted to promote
early detection of diseases and illnesses.
of the most important evidence-based guidelines for periodic health examination
were published by the US Preventive Services Task Force and the Canadian
Task Force on the Periodic Health Examination.1,2
The screening tests recommended for people aged 65 and older are limited,
probably due to inadequate evaluation of the cost-effectiveness of all
the available screening tests in the elderly population. In general, from
the available evidences, screening of blood pressure, faecal occult blood,
mammography, Pap smear, bone density screening for older women, vision
and hearing screening, were all found to be cost-effective. Many other
screening tests are controversial and are not recommended for elderly
Taiwan there was little information and evidence available to assess the
effectiveness of the periodic health examination of elderly people, although
the number of people doing periodic health examination increased rapidly
in the past 10 years. In the year 2001, it was estimated that approximately
37% of elderly people underwent free health examination offered by the
studies showed that smoking was a significant predictor of mortality for
adults, including elderly people.3-5
Consumption of alcohol is another lifestyle factor that has been associated
with mortality. Light to moderate drinking was found to be associated
with a reduction in overall mortality.6-8
Healthy dietary habits such as adequate intake of vegetables, fruits and
milk were found to be associated with good health. Obesity and overweight
were also found to be associated with mortality,9-11
while their association in elderly people was found to be different from
that in the younger population.12-14
High blood pressure and diabetes mellitus (DM) were the two chronic diseases
associated with increased mortality of elderly people.15-21
The results of laboratory tests commonly performed in the Periodic Health
Examination were found to be associated with mortality, such as white
blood cell count,22-25
serum albumin level,30-34
renal function tests,35
uric acid level,41
serum cholesterol level,42,43
serum triglyceride level,44
and levels of serum enzymes aspartate transaminase (AST) and alanine transaminase
aim of this study is to identify the significant predictors of mortality
of the study subjects from the findings of a periodic health examination
for elderly people so that health providers can follow up and care for
these people more effectively.
Since the year 1994, elderly people aged 65 and older were eligible to
attend a free periodic health examination covered by National Health Insurance
in a community hospital located in the Taipei County of Taiwan. They participated
voluntarily and attended annually in a 'first-come, first-serve' basis.
In this study, we performed analyses on the findings of the first health
examination of these elderly people who attended this hospital between
the years 1996-1999.
In this study, only the findings of the first examination of the participant
during the study period were used for analysis. Elderly people voluntarily
made an appointment and came on the day of examination in a fasting state.
The health examination included the completion of a questionnaire, a physical
examination and laboratory tests. With the help of an assistant or a nurse,
a questionnaire about medical history (hypertension, diabetes mellitus,
renal disease, lung disease, cerebrovascular disease, lipid disorder,
hepatitis B infection, cardiovascular diseases, peptic ulcer disease and
history of regular drug usage) and lifestyle (smoking, alcohol consumption,
intake of fruits, vegetables and milk) were administered. Blood pressure,
heart rate, height, weight and vision acuity were measured. A completed
physical examination was then performed by a family physician. Finally,
a panel of blood and urine tests was done, including complete blood count,
fasting sugar, lipid profile (cholesterol and triglyceride), renal function
profile (blood urea nitrogen, creatinine and urine albumin), liver profile
(serum AST and ALT), serum albumin, globulin and uric acid.
reliability of the questionnaire was estimated by comparing the responses
of the first health examination and subsequent examinations of those subjects
who attended more than once during the study period. The correlation of
their answers to the questionnaire in the first and repeated examinations
was regarded as a representation of the test-retest reliability. The mean
duration between the test and retest was 13 months. The mean correlation
coefficient was 0.62. All laboratory tests were performed in the institution's
laboratory. Blood pressure was measured once by a standard sphygmomanometer
by a nurse after sufficient rest by the participant. The same automatic
device was used to measure the height and weight of the subjects throughout
the 4 years of study.
status of survival of the subjects was ascertained by linkage to the national
mortality database. The date and the cause of death were noted for each
participant who died on or before 31 December, 2000. Personal information
on each subject was kept confidential and anonymous in data linkage and
processing. Ethical review was not required for secondary data analysis
when the study was conducted.
software SPSS V.10.0 was used for the data analysis. Cox proportional
hazard regression procedure was performed to estimate the hazard ratio
of mortality of the findings. Wald test was used to determine the significance
of this hazard ratio. All statistical tests were regarded as significant
if P < 0.05. The duration of follow-up was calculated in months and
the event was the death of the elderly subject. Multivariate analysis
was performed and the significant variables of a prediction model were
identified by backward elimination in the regression procedure.
Between 1996-1999, 4794 subjects aged 65 and older (2781 male and 2013
female) underwent the periodic health examination in our institution (Table
1). Of these, 2426 subjects had repeated the examination
in the subsequent several years and 2368 subjects did the health examination
once only during the study period. By the end of 2000, there were 271
deaths in the overall cohort of 4794. The mortality rate was 5.65% and
the main causes of death were cancer and cardiovascular diseases (Table
2). The standardized mortality rate of the participants
was estimated to be 6.19%. The cross-sectional findings of the periodic
health examination in this study were similar to other studies in Taiwan
(Tables 3,4). The
standardized mortality rate and the distribution of the causes of mortality
were also similar to the national data. Total follow-up time of all participants
was 16 7331 person-months and the median follow-up time was 34 months
(mean = 34.9 months, SD = 10.9 months, interquartile range = 24 months).
blood pressure, cardiovascular diseases and diabetes mellitus were the
three most common medical histories reported by the participants; 54.5%
regularly took medication. Most did not smoke, did not consume alcohol
regularly and reported that they ate a lot of fruits and vegetables (Table
3). Overweight and high blood pressure were the most common
abnormal physical findings. High serum level of total cholesterol, uric
acid and blood sugar were the three most common findings in the laboratory
examination (Table 4).
following factors were found in the multivariate model significantly associated
with increased risk of mortality: daily smoking; eating less than three
dishes of vegetable and two fruits every day; urine protein > 0.3 g/L;
low hemoglobin level (men £ 130 g/L, women £ 120 g/L); serum
albumin < 40 g/L and globulin > 35 g/L; serum AST level > 40
IU/L; and blood urea nitrogen level > 7.8 mmol/L (Table
In this study, we found that daily smoking, intake of less than three
dishes of vegetables and two fruits every day, low hemoglobin, excretion
of moderate amounts of urine protein, low serum albumin level, high serum
globulin level, elevated serum AST and high bood urea nitrogen (BUN) level
were significant independent predictors of mortality in the multivariate
hazard ratio of mortality was 1.401 in the elderly who smokes daily. Smoking
is similarly hazardous to elderly people as in the younger population.
Education of elderly patients to quit smoking is important in daily practice.
Nutrition deficiency is common in elderly people. Encouragement of elderly
people to eat adequate and balance food is important. Increased intake
of fruits and vegetables was shown to be protective in this study. Obesity
is a risk factor for many adult diseases. However, in the elderly population
of this study, body mass index (BMI) was not found to be a significant
risk factor of mortality. Alcohol consumption was also not shown to increase
the mortality in this study. In general, inquiry about the lifestyle issues
is still very important in the periodic health examination. Intervention
to change an unhealthy lifestyle should be considered.
is an independent factor strongly associated with mortality. In this study,
the hazard ratio of mortality for low haemoglobin was 1.924. Underlying
diseases unable to be adjusted might explain part of the increasing risk
of mortality of low haemoglobin. Identification of the causes of the anaemia
and treatment of the underlying causes may increase the survival rate
of the patient. Serum albumin levels were found to be significantly associated
with mortality. The hazard ratio of mortality found in this study for
serum albumin < 40 g/L was 2.108. Elderly people with low serum albumin
levels should be further investigated for underlying illnesses and be
treated accordingly. Elevated serum globulin > 35 g/L was also found
to be a risk factor for mortality with a hazard ratio of 1.421. Raised
serum AST level was significantly associated with mortality. The hazard
ratio was 2.468 in people with AST > 40 IU/L. Elderly people with elevated
AST should be followed-up closely, even if the patient does not have liver
disease. Further investigation is warranted if the abnormalities persist
without good explanation.
of urinary protein was an important independent indicator for health,
being significantly associated with mortality. The hazard ratio was 2.184
in this study. Elderly people with proteinuria should be followed-up closely
and other cardiovascular risk factors should be found and modified. Treatment
with angiotensin-converting enzyme (ACE) inhibitors may be considered.
Serum level of blood urea nitrogen was also found to be associated with
increased mortality, with a hazard ratio of 1.427. Supportive treatments
and correction of underlying illnesses may correct the elevated level
on the results of the health examination, we can identify high-risk elderly
people. Further treatment or management of the high-risk group may reduce
their mortality. The findings of this study also suggest that many results
in the periodic health examination are not predictors of mortality among
the elderly. This may imply that the contents of the periodic health examination
may need to be revised accordingly. In this health examination, additional
serological tests (hepatitis B surface antigen, hepatitis C antibody,
etc.), imaging studies (chest X-ray, abdominal sonography, etc.), and
other screening tests (electrocardiogram, thyroid stimulating hormone,
alpha-fetoprotein, etc.) were selectively performed. The findings of these
tests were not included in our analysis due to the incompleteness of data.
It is not known whether the results of these screening tests were predictors
of mortality. More studies should be done to evaluate the cost and effectiveness
of the contents of periodic health examinations in the future.
study has the following limitations. First, the median follow-up time
was only 34 months. The confounding effects of the underlying illnesses
or other factors can remain after such a short follow-up time. The statistical
power may not be enough for some factors with small differences in relative
risk or with small percentage rates of positive findings. Second, the
subjects may be self-selective in presenting voluntarily for the health
examination. However, the demographic structure, mortality rate and the
distribution of the causes of mortality were similar to the national data.
As a result, the generalization of the findings of this study to the elderly
population in Taiwan may be acceptable. Third, we did not have information
on time-dependent and changeable predictors which may be more useful in
patients' care. We will update the information and undertake longer follow-up
to solve this problem in future studies.
number of abnormal tests (urine protein, serum albumin and globulin, serum
AST, haemoglobin and BUN) performed in the routine periodic health examination
can provide us with valuable information to predict the mortality of elderly
people. Lifestyle factors such as smoking, intake of vegetables and fruits
are also predictors of mortality in the elderly population. Individualized
risk management plan should be formulated according to the findings of
periodic health examination in order to maximize the benefit of a periodic
health examination. The results of this study may provide evidence for
the design and revision of periodic health examinations for the elderly
in the future.
of implications for GPs
such as smoking and intake of fruits and vegetables are important
to the health of elderly people, as noted in the findings of this
study. GPs should play a central role in educating and motivating
elderly patients to pursue healthy lifestyles.
patients will ask their family doctors to explain the results
of their health check-up. With the recognition of significant
predictors of mortality, GPs can better explain and manage their
patients in the context of the findings in the health check-up.
patients ask GPs to perform tests as a part of routine check-up,
GPs can select appropriate tests that may predict mortality. The
check-up may then be more cost-effective.
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1 Age and sex of the participants
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2 Number and causes of death by the end of the study (31 December,
other causes mortality
of survived subjects
3 Self-reported medical histories and lifestyle factors of the participants
medical histories and lifestyle factors
of the conditions
(n = 4794)
fruits and vegetables frequently (at least 3 dishes of vegetable
and 2 fruits)
4. Abnormal findings of the periodic health examination in this study
of the conditions
(n = 4794)
( > 24 and < 27)
BP (< 140 mmHg)
BP (> = 140 mmHg)
BP (< 90 mmHg)
BP (< 90 mmHg)
BP ³ 90 mmHg)
(positive history or SBP > 140 mmHg or DBP > 90 mmHg)
protein (< 0.3 g/L)
protein (= 0.3 g/L)
protein (> 0.3 g/L)
blood cells (> 10.0 ´ 109/L)
(male < 130 g/L, female < 120 g/L)
(< 40 g/L)
(> 35 g/L)
AST (> 40 IU/L)
ALT (> 60 IU/L)
6.1 mmol/L and < 7 mmol/L)
or glucose intolerance (positive history or fasting sugar > 6.1
(³ 5.20 mmol/L and < 6.20 mmol/L)
(³ 6.20 mmol/L)
(³ 1.7 mmol/L and < 2.26 mmol/L)
(³ 2.26 mmol/L)
(> 7.8 mmol/L)
(> 124 mol/L)
acid (> 446 mol/L)
body mass index; BP, blood pressure; AST, aspartate transaminase; ALT,
alanine transaminase; BUN, blood urea nitrogen
5 Hazard ratios of mortality of the significant factors in the multivariate
less than 3 dishes of vegetable and 2 fruits per day
0.3 g/L 2.184
(male < 130 g/L female < 120 g/L)
40 g/L 2.108
globulin > 35 g/L
> 40 IU/L
> 7.8 mmol/L
aspartate transaminase; BUN, blood urea nitrogen
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