Red Book AMC PDF

Guidelines for preventive
activities in general practice

8th edition
Guidelines for preventive

activities in general practice
8th edition
Guidelines for preventive activities in general practice

8th edition
Disclaimer
The information set out in this publication is current at the date of first
publication and is intended for use as a guide of a general nature only and
may or may not be relevant to particular patients or circumstances. Nor is
this publication exhaustive of the subject matter. Persons implementing any
recommendations contained in this publication must exercise their own
independent skill or judgement or seek appropriate professional advice relevant
to their own particular circumstances when so doing. Compliance with any
recommendations cannot of itself guarantee discharge of the duty of care owed
to patients and others coming into contact with the health professional and the
premises from which the health professional operates.
Whilst the text is directed to health professionals possessing appropriate
qualifications and skills in ascertaining and discharging their professional
(including legal) duties, it is not to be regarded as clinical advice and, in
particular, is no substitute for a full examination and consideration of medical
history in reaching a diagnosis and treatment based on accepted clinical
practices.
Accordingly, The Royal Australian College of General Practitioners and its
employees and agents shall have no liability (including without limitation
liability by reason of negligence) to any users of the information contained in
this publication for any loss or damage (consequential or otherwise), cost or
expense incurred or arising by reason of any person using or relying on the
information contained in this publication and whether caused by reason of any
error, negligent act, omission or misrepresentation in the information.
Recommended citation
Guidelines for preventive activities in general practice, 8th edn.
East Melbourne: Royal Australian College of General Practitioners, 2012.
Published by
The Royal Australian College of General Practitioners
RACGP House
100 Wellington Parade
East Melbourne VIC 3002 Australia
T 03 8699 0414
F 03 8699 0400
www.racgp.org.au
ISBN 978-0-86906-344-6
First edition published 1989
Second edition published 1993
Third edition published 1994
Fourth edition published 1996
Fifth edition published 2001
Fifth edition (updated) published 2002
Sixth edition published 2005
Seventh edition published 2009
This eighth edition published 2012, reprinted September 2013
Cover image istockphoto/skodonnell
2012 The Royal Australian College of General Practitioners

8th edition
Acknowledgements
The Royal Australian College of General Practitioners (RACGP) gratefully acknowledges the generous
contribution of the following authors and reviewers of the Guidelines for preventive activities in general
practice (the red book) 8th edition.
Red book taskforce members

Dr Evan Ackermann
Chair, Red Book Taskforce, Chair, National Standing Committee for Quality Care, RACGP
Professor Mark Harris
Centre for Primary Health Care and Equity, University of New South Wales, National Standing Committee
for Quality Care, RACGP
Dr Karyn Alexander
General practitioner, Victoria
Dr Meredith Arcus
General practitioner, Western Australia
Linda Bailey
Project manager, Red Book Taskforce
Dr John Bennett
Chair, National Standing Committee for e-Health, RACGP
Associate Professor Pauline Chiarelli
School of Health Sciences, University of Newcastle, New South Wales
Professor Chris Del Mar
Faculty of Health Sciences and Medicine, Bond University, Queensland
Professor Jon Emery
School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, National Standing
Committee for Research, RACGP
Dr Ben Ewald
School of Medicine and Public Health, University of Newcastle, New South Wales
Dr Dan Ewald
General practitioner, New South Wales; Adjunct Associate Professor, Northern Rivers University Centre for
Rural Health; and Clinical Advisor North Coast NSW Medicare Local
Professor Michael Fasher
Adjunct Associate Professor, University of Sydney; and Conjoint Associate Professor, University of Western
Sydney, New South Wales
Dr John Furler
Department of General Practice, The University of Melbourne, Victoria
Dr Faline Howes
General practitioner, Tasmania
Dr Caroline Johnson
Department of General Practice, The University of Melbourne, Victoria, National Standing Committee
for Quality Care, RACGP
Dr Beres Joyner
General practitioner, Queensland
Associate Professor John Litt
Department of General Practice, Flinders University, South Australia, Deputy Chair, National Standing
Committee for Quality Care, RACGP
iii
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8th edition
Professor Danielle Mazza

Department of General Practice, School of Primary Care, Monash University, Victoria, National Standing
Committee for Quality Care, RACGP
Professor Dimity Pond
School of Medicine and Public Health, University of Newcastle, New South Wales
Associate Professor Lena Sanci
Associate Professor Jane Smith
Faculty of Health Sciences and Medicine, Bond University, Queensland
Dr Tania Winzenberg
Deputy Chair, National Standing Committee for Research, RACGP
Reviewers
Dr Stuart Aitken
Gold Coast Sexual Health Clinic, Queensland
Professor Adrian Bauman
School of Public Health, The University of Sydney, New South Wales
Dr Glenise Berry
Australian & New Zealand Society for Geriatric Medicine
Dr Mark Bolland
School of Medicine, The University of Auckland, New Zealand
Dr Chris Bourne
Sydney Sexual Health Centre, Sydney Hospital, New South Wales
Robert Boyd-Boland
Australian Dental Association
Professor Henry Brodaty
Dementia Collaborative Research Centre, University of New South Wales and Prince of Wales Hospital
Kate Broun
Cancer Council Victoria
Leanne Burton
NSW STI Programs Unit, Sydney Sexual Health Centre, Sydney Hospital, New South Wales
Professor Ian Caterson
Centre for Overweight and Obesity, The University of Sydney, New South Wales
Samantha Chakraborty
beyondblue
Professor Stephen Colagiuri
Institute of Obesity, Nutrition and Exercise, The University of Sydney, New South Wales
Dr Michael Crampton
National Immunisation Committee
Dr Michael DEmden
Diabetes Australia
Dr Joanne Dixon
Human Genetics Society of Australasia
Professor Peter Ebeling
Osteoporosis Australia
Associate Professor Matt Edwards
Department of Paediatrics, University of Western Sydney, New South Wales
Professor John Eisman
Garvan Institute of Medical Research, New South Wales

8th edition
Shelley Evans
Osteoporosis Australia
Dr Linda Foreman
General practitioner, Adelaide, South Australia
Professor Robert Goldney
Discipline of Psychiatry, The University of Adelaide, South Australia
Associate Professor Jane Halliday
Public Health Genetics, Murdoch Childrens Research Institute, Victoria
Associate Professor Kelsey Hegarty
Kelvin Hill
National Stroke Foundation
Dr Elizabeth Hindmarsh
General practitioner, Sydney, New South Wales
Barbara Hocking
Sane Australia
Dr Cathy Hutton
National Immunisation Committee
Professor Henry Krum
Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Victoria
Professor Stephen Lord
Neuroscience Research Australia
Professor Finlay Macrae
Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Victoria
Professor Rebecca Mason
Australian & New Zealand Bone and Mineral Society
Associate Professor Tim Mathew
Kidney Health Australia
Associate Professor Sylvia Metcalfe
Genetics Education & Health Research, Murdoch Childrens Research Institute, Victoria
Dr Viviene Milch
National Breast and Ovarian Cancer Centre, New South Wales
Carolyn Murray
NSW STI Programs Unit, Sydney Sexual Health Centre, Sydney Hospital, New South Wales
Professor Mark Nelson
Menzies Research Institute, University of Tasmania
Professor Ian Olver
Cancer Council Australia
Dr Rod Pearce
Australian Technical Advisory Group on Immunisation
Dr Carole Pinnock
Repatriation General Hospital, Flinders University, South Australia
Professor Ian Reid
Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
Ann Robertson
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Professor Ann Roche
National Centre for Education and Training on Addiction, Flinders University, South Australia
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8th edition
Dr Jeff Rowland
Australian & New Zealand Society for Geriatric Medicine
Professor John Saunders
Consultant Physician in Internal Medicine and Addiction Medicine, Sydney, New South Wales
Associate Professor Jonathan Shaw
Baker IDI Heart & Diabetes Institute, Victoria
Professor James St John
Dr Graeme Suthers
South Australia Clinical Genetics Service, South Australia
Shanthi Thuraisingam
National Heart Foundation of Australia
Professor Stephen Twigg
Central Clinical School, The University of Sydney, New South Wales
Dr Angela Taft
Mother and Child Health Research, La Trobe University, Victoria
Jinty Wilson
Heart Foundation and National Vascular Prevention Disease Alliance
Dr Brendan White
Australian Dental Association (NSW Branch), New South Wales
Dr Clive Wright
Chief Dental Officer, NSW Health, New South Wales
Professor Nicholas Zwar
School of Public Health and Community Medicine, University of New South Wales, New South Wales
Members of the Australian & New Zealand Society for Geriatric Medicine Council
Members of the Australian Dental Association Oral Health Committee
Members of the Paediatrics & Child Health Division, Royal Australasian College of Physicians
Representatives from Cancer Council Victoria
Organisational representatives
Lisa Dive
Royal Australasian College of Physicians
Chris Enright
Engy Henein
Royal Australasian College of Physicians
Ruth Hertan
National Stroke Foundation and National Vascular Disease Prevention Alliance
Diana Reddan
National Stroke Foundation
Jared Slater
Optometrists Association Australia
We gratefully acknowledge the expert reviewers and representatives from the above organisations
who contributed scholarly feedback.

8th edition
Abbreviations and acronyms

13vPCV
13-valent pneumococcal conjugate vaccine
23vPPV
Pneumococcal polysaccharide vaccine
ABCD
Asymmetry, border, colour, diameter
ABI
Ankle:brachial index
ACE
Angiotensin converting enzyme
ACR
Albumin-creatinine ratio
AF
Atrial fibrillation
ALA
dTPa Diphtheria,tetanus, acellular pertussis (adolescent/

adult version)
DXA
Dual-energy X-ray absorptiometry
ECG
Electrocardiograph
EFG
Elevated, firm, growing for more than 1 month
eGFR
Estimated glomerular filtration rate
ESRD
End stage renal disease
Alpha-linolenic acid
FAP
Familial adenomatous polyposis
AMD
Aged-related macular degeneration
FH
Familial hypercholesterolaemia
APC
Adenomatous polyposis coli
FOBT
Faecal occult blood test
ASCIA The Australasian Society of Clinical Immunology

and Allergy
GFR
Glomerular filtration rate
GP
General practitioner
AUSDRISK Australian Type 2 Diabetes Risk Assessment Tool
HbA1c
Glycated haemoglobin
BCG
Bacillus Calmette-Gurin
HCG
Human chorionic gonadotrophin
BMD
Bone mineral density
HDL
High density lipoprotein
BMI
Body mass index
HDL-C
High density lipoprotein-cholesterol
BNP
B-type natriuretic peptide
hepA
Hepatitis A
BP
Blood pressure
hepB
Hepatitis B
BRCA1
Breast cancer susceptibility gene 1
HFE (gene)
Haemochromatosis
BRCA2
Breast cancer susceptibility gene 2
Hib
Haemophilus influenzae type b
CA
Cancer antigen
HIV
Human immunodeficiency virus
CA125
Cancer antigen 125
HNPCC
Hereditary non-polyposis colon cancer
CF
Cystic fibrosis
HPV
Human papillomavirus
CHD
Coronary heart disease
CKD
Chronic kidney disease
HSIL
High grade squamous intraepithelial lesion
COPD
Chronic obstructive pulmonary disease
IADL
Instrumental activities of daily living
CRC
Colorectal cancer
IFG
Impaired fasting glucose
CRP
High sensitivity C-Reactive Protein
IGT
Impaired glucose tolerance test
CT
Computerised tomography
IPV
Inactivated poliomyelitis
CVD
Cardiovascular disease
IS
Intussuseption
DBP
Diastolic blood pressure
LDL
Low density lipoprotein
DNA
Deoxyribonucleic acid
LDL-C
Low density lipoprotein-cholesterol
DLCN
Dutch Lipid Clinic Network (criteria)
LSIL
Low grade squamous intraepithelial lesion
DPA
Docosapentaenoic acid
LUTS
Lower urinary tract symptoms
DRE
Digital rectal examination
LVH
Left ventricular hypertrophy
DT
Diphtheria,tetanus
MBS
Medicare Benefits Schedule
MMR
Measles, mumps and rubella
MMRV
Measles, mumps, rubella and varicella
DTpa Diphtheria,tetanus, acellular pertussis

(child version)
vii
viii

8th edition
MMSE
Mini-Mental State Examination
MRI
Magnetic resonance imaging
MSM
Men who have sex with men
MSU
Midstream urine
MUKSB
Modified UK Simon Broome criteria
NAAT
Nucleic acid amplification test
NHMRC
National Health and Medical Research Council
NIP
National Immunisation Program
NIPS
National Immunisation Program Schedule
NMSC
Non-melanoma skin cancer
NTD
Neural tube defect
PCR
Polymerase chain reaction
PEDS
Parents evaluation of developmental status
PET-CT Positron Emission Tomography Computed

Tomography
PND
Postnatal depression
RACGP
The Royal Australian College of General Practitioners
RCT
Randomised controlled trial
SBP
Systolic blood pressure
SES
Socioeconomic status
SIDS
Sudden infant death syndrome
SNAP
Smoking, nutrition, alcohol, physical activity
SPF
Sun protection factor
STIs
Sexually transmitted infections
TG
Triglyceride
TIA
Transient ischaemic attack
TUGT
Timed up and go test
UACR
Urine Albumin-to-Creatinine Ratio
VV
Varicella Vaccination
VZV
Varicella Zoster Virus
WHO
World Health Organization

8th edition
Contents
I. Introduction
The Australian experience
Preventive health activities
Screening versus case finding
Screening principles
II. Patient education and health literacy
Impact of patient education
Approaches to patient education
The complex needs and health problems of disadvantaged groups
III. Development of the red book
Sources of recommendations
Scope and limitations of the red book
IV. How to use the red book
Organisational detail
V. Whats new in this 8th edition?
1. Preventive activities prior to pregnancy
11
11
What does pre-conception care include?
2. Genetic counselling and testing
14
3. Preventive activities in children and young people
17
17
Early intervention
4. Preventive activities in middle age
26
5. Preventive activities in older age
28
5.1 Immunisation
28
5.2 Falls and physical activity
29
5.3 Visual and hearing impairment
31
5.4 Dementia
32
6. Communicable diseases
34
6.1 Immunisation
34
6.2 STIs
37
7. Prevention of chronic disease
40
7.1 Smoking
42
7.2 Overweight
43
7.3 Nutrition
45
7.4 Early detection of problem drinking
47
7.5 Physical activity
49
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8th edition
8. Prevention of vascular and metabolic disease
50
8.1 Assessment of absolute cardiovascular risk
50
8.2 BP
51
8.3 Cholesterol and other lipids
53
8.4 Type 2 diabetes
55
8.5 Stroke
57
8.6 Kidney disease
58
9. Early detection of cancers
60
9.1 Skin cancer
60
9.2 Cervical cancer
63
9.3 Breast cancer
65
9.4 Ovarian cancer
67
9.5 Oral cancer
68
9.6 CRC(bowel cancer)
68
9.7 Testicular cancer
71
9.8 Prostate cancer
71
10. Psychosocial
73
10.1 Depression
73
10.2 Suicide
75
10.3 Identification of intimate partner violence
76
11. Oral hygiene
78
12. Glaucoma
79
13. Urinary incontinence
80
14. Osteoporosis
82
15. Screening tests of unproven benefit
85
References 87
Appendix 1: Dutch Lipid Clinic Network Criteria for making a diagnosis
115
of Familial Hypercholesteroloemia (FH) in adults

Appendix 2: Red flag early intervention referral guide
117
Appendix 3: Audit-C (available for use in the public domain)
118
Appendix 4:The Australian Type 2 Diabetes Risk Assessment tool AUSDRISK
120
Appendix 5: Australian cardiovascular risk charts
122
Appendix 6:The three incontinence questions
124
Glossary
125

8th edition
I. Introduction
General practice is at the forefront of healthcare in Australia and in a pivotal position to deliver preventive healthcare.
More than 125 million general practice consultations take place annually in Australia and 83% of the Australian
population consult a general practitioner (GP) at least once a year.1 Preventive healthcare is an important activity in
general practice. Preventive healthcare includes the prevention of illness, the early detection of specific disease, and the
promotion and maintenance of health. Preventive care is based on a partnership between a GP and a patient, designed
to help each patient reach their goals of maintaining or improving health.
Prevention is the key to Australias future health both individually and collectively. It is estimated that 80% of premature
heart disease, stroke and type 2 diabetes and 40% of cancer could be prevented through interventions that lead to
healthy diet, regular physical activity and avoidance of tobacco products.2 Preventive care is also critical in addressing
the health disparities faced by disadvantaged and vulnerable population groups.
To facilitate evidence-based preventive activities in primary care, The RACGP has published the Guidelines for preventive
activities in general practice (the red book) since 1989. The red book is now widely accepted as the main guide to the
provision of preventive care in Australian general practice.
The red book provides a comprehensive and concise set of recommendations for patients in general practice with
additional information about tailoring risk and need. It provides the evidence base for which primary healthcare
resources can be used efficiently and effectively while providing a rational basis to ensure the best use of time and
resources in general practice.
The red books companion publication, National guide to a preventive health assessment for Aboriginal and Torres
Strait Islander peoples (2nd edition), is intended for all health professionals delivering primary healthcare to the
Aboriginal and Torres Strait Islander population.
The Australian experience

Health reform in Australia has led to a renewed focus on preventive healthcare. The role of general practice in
prevention has been recognised by the Council of Australian Governments3 and by the Australian Governments
Preventative Health Taskforce and Primary Health Care Strategy.4,5
Deaths and hospitalisations from preventable illness have continued to decline within Australia. Still, the leading causes of
death and disability in Australia are preventable or able to be delayed by early treatment and intervention (Figure 1).6
Figure 1. Potentially avoidable deaths
Reproduced with permission from the Australian Institute of Health and Welfare. Australias health 2012.
Australias health series no. 13, cat. no. AUS 156. Canberra: AIHW, 2012.6

8th edition
A recent Australian review7 concluded that lifestyle interventions could have a large impact on population health. The
cardiovascular absolute risk approach and screening for diabetes and chronic kidney disease (CKD) were also given
high priority for action.
Despite this evidence and wide acceptance of its importance, real and perceived barriers have meant preventive
interventions in general practice remain underutilised, being the primary reason for the consultation in only seven of every
hundred clinical encounters.8 This is small when it is considered that preventable chronic diseases, along with biomedical
risk factors, account for approximately one-fifth of all problems currently managed in Australian general practice.9
Each preventive activity uses up some of the available time that GPs have to spend with their patients. It may also
involve direct or indirect costs to the patient. Much more needs to be done to support and improve proper evidencebased preventive strategies, and to minimise practices that are not beneficial or have been proven to be harmful. The
RACGP has been championing this cause since foundation, and encourages all general practices, GPs and their
teams to prioritise appropriate preventive health activities within their practices.
Preventive health activities

Prevention is better than cure is an instinctive concept and its appeal is embedded in the medical and political
culture. Yet we now know from the evidence that some preventive activities are not always effective or appropriate;
indeed, some are quite harmful.
Many preventive activities have the potential to be associated with harm. For example, screening may lead to
overdiagnosis, causing needless anxiety, appointments, tests, drugs and even operations. Therefore, it is crucial that
evidence clearly demonstrates that benefits outweigh those harms for each preventive activity.
While greater societal awareness and attention on preventive activities is important, challenges are presented by
the involvement of single-disease health groups, special interest societies and specialist groups that only visualise a
refined subset of patients. These groups often utilise marketing strategies to promote their cause, and this often results
in confusing messages for GPs and their patients. Determining whether a preventive activity is beneficial, harmful or
of indeterminate effect (there is not enough evidence on which to base a decision) requires a consistent, unbiased,
evidence-based approach.
No area typifies this more clearly than the area of cancer screening. The even-handed interpretation of evidence,
balancing harms and benefits, managing overdiagnosis and overtreatment, has been a goal of those drafting the
prostate and breast cancer sections of the red book since the early editions. These screening activities have polarised
different sectors of the health professions.
The RACGP looks forward to resolving the controversies surrounding contentious areas of screening to assist GPs in
caring for their patients. In these guidelines, only those screening activities where evidence demonstrates that benefits
outweigh harms have been included. Section 15 of the red book provides some guidance on common tests where this
is not the case.
Screening versus case finding

Screening has been defined as the examination of asymptomatic people in order to classify them as likely or unlikely
to have a disease.10 The primary purpose of screening tests is to detect early disease in apparently healthy individuals.
In these guidelines screening usually refers to early detection using questions or a test, which GPs perform either
when patients present for preventive care or opportunistically when patients present for other reasons. Proactive recall
of patients for screening is warranted for high-risk groups, or for conditions where population coverage has been
identified by the government as a public health priority. These include immunisation and screening for cervical, breast
and colorectal cancers (CRC) and diabetes.
Screening tests are not case finding or diagnostic tests. The purpose of a diagnostic test is to establish the
presence (or absence) of disease as a basis for treatment decisions in symptomatic or screen-positive individuals
(confirmatory test), for example, taking a midstream urine (MSU) sample for evaluation of a urinary tract infection, or
performing mammography for a suspicious breast lump.

8th edition
Screening and case finding carry different ethical obligations. If the practitioner initiates the screening, there needs
to be conclusive evidence that the procedure can positively affect the natural history of the disorder. Moreover, the
risks of screening in asymptomatic individuals must be carefully considered as the patient has not asked the health
professional for assistance. This situation is somewhat different from case finding, where the patient has presented
with a particular problem or has asked for some level of assistance. In this situation, there is no guarantee of benefit
of the tests undertaken and, it could be argued, there is at least some implied exposure to risk (as in performing
colonoscopy to investigate abdominal pain). Many health practitioners confuse the difference between screening
and case-finding tests. This often obscures the arguments surrounding the benefits and harms of screening tests.
Screening principles
The World Health Organization (WHO) has produced guidelines11,12 for the effectiveness of screening programs.
We have kept these and the United Kingdom National Health Services guidelines13 in mind in the development of
recommendations about screening and preventive care.
The condition
It should be an important health problem.
It should have a recognisable latent or early symptomatic stage.
The natural history of the condition, including development from latent to declared disease, should be adequately
understood.
The test
It should be simple, safe, precise and validated.
It should be acceptable to the target population.
The distribution of test values in the target population should be known and a suitable cut-off level defined and
agreed.
Treatment
There should be an effective treatment for patients identified with evidence that early treatment leads to better
outcomes.
There should be an agreed policy on who should be treated and how.
Outcome
There should be evidence of improved mortality, morbidity or quality of life as a result of screening and that the
benefits of screening outweigh the harm.
The cost of case finding (including diagnosis and treatment of patients diagnosed) should be economically
balanced in relation to possible expenditure on medical care as a whole.
Consumers
Consumers should be informed of the evidence so that they can make an informed choice about participation.
Screening activities in general practice are complex; they involve patients accessing care as well as general
practices adopting systematic approaches to registering and recalling patients, and organising their efforts
to maximise the effectiveness of each consultation in providing preventive care.14 Effective screening requires
consideration of subgroups in the population who may have a higher prevalence of a disease or risk factor, or who
may have difficulty accessing services.15
In Australia, there is an increasing number of Medicare items for health assessments in particular population
groups: preschool children, Aboriginal children and adults, refugees, people with an intellectual disability, those
aged 4549 years (with a risk factor), and those aged 75 years or over. There is evidence that these assessments
improve the likelihood of preventive care being received.16 However, it is important that such health checks involve
preventive interventions for which there is clear evidence of their effectiveness.

8th edition
II. Patient education and health literacy

Impact of patient education
Patient education and counselling contribute to behaviour change for primary prevention of disease17. More broadly,
they may also help create greater health literacy the knowledge and skills patients require to maintain their
own health, including use of health services. The use of behavioural techniques, especially for self-monitoring, is
recommended, as is the use of personal communication and written or other audiovisual materials.17
Patients view the GP as a key first contact and credible source of preventive advice.
Factors that increase the effectiveness of patient education delivered by GPs include:
assessing the patients health literacy18
the patients sense of trust in their GP19
face-to-face delivery20
patient involvement in decision-making2123
highlighting the benefits and the costs24, 25
strategies to help the patient remember what they have been told26
tailoring the information to the patients interest in change27
strategies that address the difficulty in adherence23, 28
the use of decision aids.29
Many prevention activities involve a change in health-related behaviour. As the patient plays a large role in making this
happen, it is useful to facilitate more active inclusion of patients in their care. This process is an essential component
of self-management strategies30, 31 and has the potential to increase the patients responsibility for their health. In
addition, it:
enhances the quality of communication32, 33
enhances the patient-doctor consultation21
can reduce the cost of aspects of care through better informed patients22
increases the demand and use of appropriate referral to other health professionals and agencies32
increases adherence to recommended prevention activities and therapeutic regimens.32, 34
For those whose first language is not English, a professional interpreter should be considered.
Approaches to patient education

Patients need to develop their own understanding of the problem and what can be done about it. For simple
behavioural changes, such as having a Pap test, patients weigh up the perceived benefits and costs.35 These benefits
and costs may include answers to the following questions.
How big is the problem to the individual?
What are the consequences of not doing the test?
What are the benefits?
What are the barriers?
Some health education may require more complex actions over a period of time such as changing diet, stopping
smoking or increasing physical activity. The stages of change model36 identifies five basic stages of change, which
are viewed as a cyclical, ongoing process during which the person has differing levels of motivation or readiness
to change, and the ability to relapse or repeat a stage. Each time a stage is repeated, the person learns from the
experience and gains skills to help them move to the next stage.

8th edition
Table II.1 Stages of change model

Pre-contemplation
(Not thinking about change)
The person does not consider the need to change
Contemplation
(Thinking of change)
The person considers changing a specific behaviour
Has not had sufficient experience with negative consequences.

Begins to seek relevant information.
Re-evaluates behaviour.
Obtains help from others to support future attempts.
Still weighs up options and isnt ready to take action.
Determination
(Ready for change)
The person makes a serious commitment to change

Is ready to take action in the next 30 days.
Needs to set goals and develop priorities in order to manage their illness.
Action
(Changing behaviour)
Change begins (these can be large or small changes)

Makes efforts to modify habits and environment.
Increasingly uses behavioural processes of change (e.g. stimulus control and
counter-conditioning).
Maintenance
(Maintaining change)
Change is sustained over a period of time

Counter-conditioning and self-liberation peak.
Takes responsibility for actions.
Is susceptible to relapse so remain aware of environmental and internal stimuli that
may trigger problem behaviours.
Motivational interviewing is dealt with in more detail in the RACGP green book.
The complex needs and health problems of disadvantaged groups

The complex needs and health problems of disadvantaged groups and the interactions between social,
psychological, environmental and physical determinants of health mean that special effort is required for patient
education to be effective. In particular, GPs need to employ a range of strategies and work in collaboration with
other services.37 To be effective in patient education for Indigenous communities, GPs need an understanding of
the Aboriginal and Torres Strait Islander view of health, culture and history and an ability to provide services within a
culturally appropriate framework. This also requires GPs to collaborate with other agencies and providers to ensure
the provision of high-quality preventive healthcare for Indigenous Australians.38

8th edition
III. Development of the red book

These Guidelines for preventive activities in general practice, 8th edition, have been developed by a taskforce of
GPs and experts to ensure that the content is the most valuable and useful for GPs and their teams. The guidelines
provide an easy, practical and succinct resource. The content broadly conforms to the highest evidence-based
standards according to the principles underlying the Appraisal of Guidelines Research and Evaluation.39, 40
The dimensions addressed are:
scope and purpose
clarity of presentation
rigour of development
stakeholder involvement
applicability
editorial independence.
The red book maintains developmental rigour, editorial independence, relevance and applicability to general practice.
The Red Book Taskforce also welcomes its companion document, the National guide to a preventive health
assessment for Aboriginal and Torres Strait Islander peoples, 2nd edition (the National guide). This publication is a
collaborative effort with the National Aboriginal Community Controlled Health Organisation and the RACGP National
Faculty of Aboriginal and Torres Strait Islander Health, and is intended for all health professionals delivering primary
healthcare to the Aboriginal and Torres Strait Islander population. For preventive care to be most effective, it needs
to be planned, implemented and evaluated. Planning and engaging in preventive health is increasingly expected by
patients. The RACGP thus provides the red book and National guide to inform evidence-based guidelines, and the
green book to assist in development of programs of implementation. The RACGP is planning to introduce a small set
of voluntary clinical indicators to enable practices to monitor their preventive activities.
Sources of recommendations
The recommendations in these guidelines are based on current, evidence-based guidelines for preventive activities. We
focused on those most relevant to Australian general practice. Usually this means that the recommendations are based
on Australian guidelines such as those endorsed by the National Health and Medical Research Council (NHMRC).
In cases where these are not available or recent, other Australian sources have been used, such as guidelines
from the Heart Foundation, Canadian or United States preventive guidelines, or the results of systematic reviews.
References to support these recommendations are listed. However, particular references may relate to only part of
the recommendation (e.g. only relating to one of the high-risk groups listed) and other references in the section may
have been considered in formulating the overall recommendation.
Scope and limitations of the red book

These guidelines have not included detailed information on the management of risk factors or early disease (e.g.
what medications to use in treating hypertension). Similarly, they have not made recommendations about tertiary
prevention (preventing complications in those with established disease). Also, information about prevention of
infectious diseases has been limited largely to immunisation and some sexually transmitted infections (STIs).
There is limited advice about travel medicine. Information on travel medicine can be obtained from the Centres for Disease
Control and Prevention at www.cdc.gov/travel/index.htm or WHO International Travel and Health at www.who.int/ith/
These recommendations are based on the best available information at the time of writing. On past experience this
means that the guidelines will remain current for no longer than 2 years. Any update information will be posted on
the RACGP website. More information and guidelines can be found on the NHMRC website www.nhmrc.gov.au/
guidelines; the Australian Government clinical guidelines portal www.clinicalguidelines.gov.au; and the Cochrane
Collaboration website www.cochrane.org/

8th edition
IV. How to use the red book

These guidelines are designed to be used in a number of ways, all of which can be useful in day-to-day general
practice. The red book can be used as a:
guide to who is most at risk and for whom screening or preventive care is most appropriate
refresher to check the latest recommendations
reminder to check at a glance what preventive activities are to be performed in various age groups and how often
checklist of preventive activities used according to an individual patients health profile
patient education tool, to demonstrate to patients the evidence that exists for preventive activities
study guide a comprehensive list of references is provided (links to further original sources are provided in the
electronic version where appropriate). This allows more in-depth information on a particular topic.
Organisational detail
The information in these guidelines is organised into three levels.
The first level is the lifecycle chart, which highlights when preventive activities should be performed and the
optimum frequency for each activity. The lifecycle chart is organised by age and clinical topic. Simply check the
column under a particular age group to see what activities should be considered for the patient. The preventive
activities that are recommended for everyone within a particular age range, and for which there is sound research
evidence, are shaded in red while activities to be performed only in patients with risk factors or where the evidence
is not as strong are shaded in light red.
A copy of this chart can be downloaded from the RACGP website and attached to the patient record as a
systematic reminder for preventive activities. You can also use it as a wall chart, or keep it handy on your desk.
The second level is more detailed and presents a summary of recommendations in addition to tables that identify
what preventive care should be provided for particular groups in the population.
This edition of the red book adopts the most recent NHMRC levels of evidence and grades of recommendations.41
Recommendations in the tables are graded according to levels of evidence and the strength of recommendation.
The levels of evidence are coded by the roman numerals IIV while the strength of recommendation is coded by the
letters AD. Practice Points are employed where no good evidence is available. In most cases a Practice Point will
replace what has been classed in previous red book editions as level V evidence.

8th edition
Table IV.1 Coding scheme used for levels of evidence and grades of recommendation
Levels of evidence
Level
Explanation
Evidence obtained from a systematic review of level II studies
II
Evidence obtained from a randomised controlled trial (RCT)
III1
Evidence obtained from a pseudo-randomised controlled trial (i.e. alternate allocation or some
other method)
III2
Evidence obtained from a comparative study with concurrent controls:

non-randomised, experimental trial
cohort study
case-control study
interrupted time series with a control group.
III3
Evidence obtained from a comparative study without concurrent controls:

historical control study
two or more single arm study
interrupted time series without a parallel control group.
IV
Case series with either post-test or pre-test/post-test outcomes
Practice Point
Opinions of respected authorities, based on clinical experience, descriptive studies or reports of

expert committees
Grades of recommendations
Grade
Explanation
Body of evidence can be trusted to guide practice
Body of evidence can be trusted to guide practice in most situations
Body of evidence provides some support for recommendation(s) but care should be taken in its
application
Body of evidence is weak and recommendation must be applied with caution
Only key references used to formulate the recommendations are included in the tables. Where the evidence is
available on the internet, the web link is given to enable easy access to original materials.
There is also information on how the preventive care should be implemented, for example, a brief outline of the
method of screening.
Finally, there is a third level of information, which is included in implementation tables, on particular disadvantaged
population groups that may be at risk of not receiving preventive care and what should be done to increase their
chance of preventive care.

8th edition
V. Whats new in this 8th edition?

The format of this 8th edition of the red book is similar to the 7th edition and is designed to be used together with
the other preventive resources such as the RACGP publications, the green book and SNAP (smoking, nutrition,
alcohol and physical activity) guidelines. There is increased information about what should be covered in health
assessments or health checks for particular groups. Levels of evidence and recommendations are now presented
alongside What should be done? and How often?. References are listed in a separate column. We have increased
the amount of guidance, while trying to maintain brevity to improve clarity.
Table V.1 Key changes in the 8th edition

Section
Change
Genetic counselling and testing (Section 2)
Guidance on familial hypercholesterolaemia (FH) has been

added.
Preventive activities in children and young people

(Section 3)
The Australian Government has announced a Universal

Child Health Check at age 3 years. This will be introduced
in 2013 and will replace the health check at age 4 years.
The contents of the new check were not available prior
to publication of this edition. It is expected that the new
check will easily fit into the system of prevention and
promotion outlined in this section.
New information that describes evidence-based
interventions for babies of depressed mothers (as distinct
from interventions targeting the mothers depression) has
been added.
As this edition was finalised, the RACGP adopted a
document outlining the role of general practice in the
provision of healthcare to children and young adults. It
may be useful to read this document as a companion
piece to Section 3: Preventive activities in children and
young people.
Reference to new United States Preventive Services Task
Force (USPSTF) recommendations for obesity screening
and screening for depression in adolescents have been
included.
Preventive activities in older age (Section 5)
New information about possible prevention of dementia

by attention to cardiovascular risk factors has been
added.
Information about influenza vaccination has been
included.
New and more detailed information about falls
assessment and prevention has been included.
Communicable diseases (Section 6)
Chlamydia screening for both sexes up to age 29 years

has been added.
Human papilomavirus (HPV) vaccine for both sexes
commencing in 2013 has been added.
Information about combined measles, mumps, rubella,
varicella (MMRV) at 18 months to be both the second
dose of measles, mumps, rubella (MMR) and the first
dose of varicella vaccine has been added.
10

8th edition
Section
Change
Prevention of chronic disease (Section 7)
New recommendations about weight management (in

line with the new NHMRC guidelines) including diet and
physical activity strategies have been included.
Prevention of vascular and metabolic disease (Section 8)
There is greater emphasis on assessment and

management of cardiovascular risk for patients aged
4574 years (in line with the new NHMRC guidelines). This
includes treatment targets for blood pressure (BP) and
lipids and new recommendations for screening as well as
management of high-risk patients for renal disease.
Early detection of cancers (Section 9)
This section has been updated with new evidence;

however, little has changed in the recommendations for
screening for most cancers.
Attention is drawn to possible changes in
recommendations for cervical cancer (Pap) screening
as new national guidelines are being prepared by the
National Cervical Screening Program.
CRC guidelines have been updated and provide more
information, which may help GPs decide if a patient is at
high risk.
Prostate cancer screening remains controversial. New
trial data do not provide unequivocal directions to screen
or not screen for prostate cancer using the PSA test,
with or without digital rectal examination (DRE). The
medical community remains divided on the issues. From
a general practice viewpoint, it is unclear whether the
advantages of screening (still very uncertain) outweigh
the harms (becoming more clearly defined). The updated
recommendation is to not raise the issue with every
eligible man, but wait until you are asked about screening.
In light of many other proven preventive activities that
could be more usefully addressed in men, we believe that
prostate cancer screening remains low on the priority list.
Oral hygiene (Section 11)
Additional advice on oral health messages is included

from an Australian National Consensus workshop
conducted in 2011.
The Lift the lip dental check for early identification of oral
problems has been added.
Glaucoma (Section 12)
Updated recommendations in line with new NHMRC

guidelines from 2010 have been added.
Osteoporosis (Section 14)
Details of risk factors have been refined.

Changes to criteria for recommending bone mineral
density (BMD) measurement have been included.
Guidance on frequency of BMD measurement have been
added.
Recommendation to use absolute risk estimation to aid
decision-making has been included.
Cautionary notes on use of calcium supplementation have
been included.
Evidence levels have been clarified.

8th edition
11
1. Preventive activities prior to pregnancy

Age
<2
23
49
1014 1519 2024
2529
3034
3539
4044
4549
5054
5559
6064
Every woman aged 1549 years should be considered for pre-conception care (C). Pre-conception care is a set
of interventions that aim to identify and modify biomedical, behavioural and social risks to a womans health or
pregnancy outcome through prevention and management.42 This should include smoking cessation (A)43 and
advice to consider abstinence from alcohol (especially in the early stages of pregnancy),44 folic acid and iodine
supplementation (A),45, 46 review of immunisation status (C),47 medications (B)48 and chronic medical conditions,
especially glucose control in patients with diabetes (B).49
There is evidence to demonstrate improved birth outcomes with pre-conception healthcare in women with
diabetes, phenylketonuria and nutritional deficiency50 as well as benefit from the use of folate supplementation
and a reduction in maternal anxiety.51 The information below lists all the potential interventions that have been
recommended by expert groups in pre-conception care (C).
What does pre-conception care include?

Medical issues
Reproductive life plan
Assist your patient in developing a reproductive life plan that includes whether they want to have children. If they do,
discuss the number, spacing and timing of intended children.
Reproductive history
Ask if there have been any problems with previous pregnancies such as infant death, foetal loss, birth defects
particularly neural tube defects (NTD), low birthweight, pre-term birth, or gestational diabetes. Are there any ongoing
risks that could lead to a recurrence in a future pregnancy?
Medical history
Ask if there are any medical conditions that may affect future pregnancies. Are chronic conditions such as diabetes,
thyroid disease, hypertension, epilepsy and thrombophilia well managed?
Medication use
Review all current medications including over-the-counter medications, vitamins and supplements.
Genetic/family history
Assess risk of chromosomal or genetic disorders, (e.g. cystic fibrosis (CF), fragile X, TaySachs disease,
thalassaemia, sickle cell anaemia and spinal muscular atrophy), by collection of data on family history and ethnic
background. Provide opportunity for carrier screening for these and other more common genetic conditions.
General physical assessment

Conduct Pap test and breast examinations before pregnancy if indicated or due. Also assess body mass index
(BMI), and BP and ask about periodontal disease.
Substance use
Ask about tobacco, alcohol and illegal drug use.
65
12

8th edition
Vaccinations
Vaccinations can prevent some infections that may be contracted during pregnancy. If previous vaccination history
or infection is uncertain, testing should be undertaken to determine immunity to varicella and rubella. Women
receiving live viral vaccines such as MMR and varicella should be advised against becoming pregnant within 28
days of vaccination. Recommended vaccinations are:
MMR
varicella (in those without a clear history of chickenpox or who are non-immune on testing)
influenza (recommended during pregnancy to protect against infection if in second or third trimester during
influenza season)
diphtheria, tetanus, pertussis (DTpa) (to protect newborn from pertussis).
Lifestyle issues
Family planning
Based on the patients reproductive life plan (see above), discuss fertility awareness and how fertility reduces
with age, chance of conception, and risk of infertility and foetal abnormality. For patients not planning to become
pregnant, discuss effective contraception and emergency contraceptive options.
Folic acid supplementation

Women should take a 0.40.5 mg supplement of folic acid per day for at least 1 month prior to pregnancy, and for
the first 3 months after conception. In women at high risk (i.e. with a reproductive or family history of NTD, women
who have had a previous pregnancy affected by NTD, women on anti-epileptics, and women who have diabetes)
the dose should be increased to 5 mg per day.
Healthy weight, nutrition and exercise

Discuss weight management and caution against being overweight or underweight. Recommend regular,
moderate-intensity exercise and assess risk of nutritional deficiencies (e.g. vegan diet, lactose intolerance, calcium
or iron and vitamin D deficiency due to lack of sun exposure).
Psychosocial health
Provide support and identify coping strategies to improve your patients emotional health and wellbeing.
Smoking, alcohol and illegal drug cessation (as indicated)

Smoking, illegal drug and excessive alcohol use during pregnancy can have serious consequences for an unborn
child and should be stopped prior to conception.
Healthy environments
Repeated exposure to hazardous toxins in the household and workplace environment can affect fertility and
increase the risk of miscarriage and birth defects. Discuss the avoidance of TORCH infections: Toxoplasmosis,
Other such as syphilis, varicella, mumps, parvovirus and human immunodeficiency virus (HIV) Rubella,
Cytomegalovirus, Herpes simplex.
Toxoplasmosis: avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk products, and wash
all fruit and vegetables.
Cytomegalovirus, parvovirus B19 (fifth disease): discuss importance of frequent handwashing, and child and
healthcare workers further reducing risk by using gloves when changing nappies.
Listeriosis: avoid pat, soft cheeses (feta, brie, blue vein), pre-packaged salads, deli meats and chilled/smoked
seafood. Wash all fruit and vegetables before eating. Refer to Australian food standards at www.foodstandards.
gov.au/foodmatters/pregnancyandfood.cfm regarding folate, listeria and mercury.
Fish: limit fish containing high levels of mercury.

8th edition
13
Table 1.1 Pre-conception: preventive interventions

Intervention
Technique
References
Folate
supplementation
High-risk women: 5 mg/day supplementation ideally beginning at least 1 month prior

to conception and for first trimester.
45, 5254
Most women: 0.5 mg/day supplementation ideally beginning at least 1 month prior to
conception and for first trimester.
Iodine
supplementation
All women who are pregnant, breastfeeding or considering pregnancy should take an
iodine supplement of 150 micrograms (g) each day.
46
Smoking
cessation
Women should be informed that tobacco affects foetal growth and all women should
be advised to stop smoking. Evidence exists to suggest improved cognitive ability
in children of mothers who quit smoking during gestation (III,A). Pharmacotherapy
should be considered when a pregnant woman is otherwise unable to quit, and when
the likelihood and benefits of cessation outweigh the risks of pharmacotherapy and
potential continued smoking.
55
Alcohol and illicit

drug use
For women who are pregnant or planning a pregnancy, not drinking is the safest
option. The risk of harm to the foetus is highest when there is high, frequent, maternal
alcohol intake. The risk of harm to the foetus is likely to be low if a woman has
consumed only small amounts of alcohol before she knew she was pregnant. Women
should be informed that illicit drugs may harm foetuses and advised to avoid use.
44
Interpregnancy
interval
There are worse perinatal outcomes with interpregnancy intervals <18 months or
>59 months, namely preterm birth, low birth weight and small for gestational age.
56
Chronic diseases
Optimise control of existing chronic diseases (e.g. diabetes, hypertension, epilepsy).
54
Avoid teratogenic medications.

Pre-conception
care resources for
GPs and patients
Address risk factors using Pregnancy Lifescripts

(resources are in process of being updated in 2012).
Health inequity
About half of women in Victoria, New South Wales and South Australia supplement their diet with folate periconceptionally. This figure is lower in: 57
women in lower socioeconomic groups
Indigenous women
rural women
younger women
multiparous women.
Strategy
As per general principles as discussed in Section I: Introduction and as outlined in the RACGP green book.
Population health surveys in three states (New South Wales 200708, Australian Capital Territory 200708 and
Tasmania 2009) showed that about half of all Australian mothers took folic acid supplements just prior to and
during their first trimester of pregnancy, as recommended. Supplement use was lower in mothers without tertiary
qualifications and in those living in more disadvantaged and remote areas.
14

8th edition
2. Genetic counselling and testing

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
There is evidence to recommend offering specific genetic tests to pregnant women, couples planning a pregnancy,
and neonates (as part of the newborn screening program) (C). Other genetic tests are appropriate for certain
conditions where the individual is considered to be at increased risk (A).
In order to identify patients who may potentially benefit from genetic testing, the GP must ensure that a
comprehensive family history is taken from all patients including first-degree or second-degree relatives (A) and
regularly updated. A family history should ideally extend to three generations, covering both sides of the family and
ethnic background. Age of onset of disease and age of death should be recorded where available.
The presence of genetically determined disease may be suggested by increased frequency and early onset of
cancers in families, premature ischaemic heart disease or sudden cardiac death, intellectual disability, multiple
pregnancy losses, stillbirth or early death, and children with multiple congenital abnormalities. Also, patients of
particular ethnic backgrounds may be at increased risk and benefit from genetic testing for specific conditions.
Possible consanguinity (cousins married to each other) should be explored, for example, by asking, Is there any
chance that a relative of yours might be related to someone in your partners family?. GPs should consider referral
to or consultation with a genetic service (general or cancer genetics) for testing because test results, (which rely on
sensitivity, specificity and positive predictive value) are not straightforward. Testing often involves complex ethical,
social and legal issues. Waiting lists for genetic services are usually more than 1 month, so direct consultation and
liaison by telephone are necessary when the genetic advice could affect a current pregnancy.
Table 2.1 Genetic testing: identifying risks

Who is at risk?
What should be done?
How often?
Assess their probability of

having FH using the Dutch
Lipid Clinic Network (DLCN)
criteria or Modified UK
Simon Broome (MUKSB)
criteria (III,B) (Appendix 1)
At first
presentation
References
Breast and ovarian cancer
See Section 9.3: Breast cancer

Colon cancer
See Section 9.6: CRC (bowel cancer)

FH
Increased risk
Premature ischaemic heart disease (men aged <55
years, women aged <60 years)
First-degree relative with premature ischaemic heart
disease (men aged <55 years, women aged <60 years)
Total cholesterol >7.5 or LDL-C >4.9
First-degree relative with a total cholesterol >7.5 or
LDL-C >4.9
Tendon xanthomata or arcus cornealis at age <45 years
Offer referral to a lipid

disorders clinic if DLCN
score >3 or the MUKSB
suggests possible FH
5860

8th edition
Who is at risk?
How often?
References
Offer referral for genetic

counselling and testing (III,B)
Test couple
prior to
pregnancy or
in first trimester
6163
In first or
second
trimester
6367
In first or
second
trimester
64
At first
presentation
63, 6870
Cystic fibrosis
Increased risk
Northern European or Ashkenazi Jewish ancestry
Family history of CF, or a relative with a known CF
mutation
Where partner is affected or is a known carrier of CF
Partners from Northern European, Ashkenazi Jewish
backgrounds who are consanguineous (cousins married
to each other)
If patient is pregnant, contact

genetic services to organise
screening in first trimester
Men with infertility suspected or due to congenital

absence of the vas deferens
Down syndrome
At risk
All pregnant women
Combined maternal serum

and ultrasound screening in
first trimester
Maternal serum screening in
second trimester* (C)
Significantly increased risk

Women who have had a previous Down syndrome
pregnancy
Women with positive maternal serum screening/nuchal
translucency ultrasound in first trimester or maternal
serum screening in second trimester
Foetal diagnostic genetic

testing (C)
Offer referral for genetic
counselling
Parent with a chromosomal rearrangement (e.g.

balanced translocation of chromosome 21)
Hereditary haemochromatosis (HFE)
Increased risk
Patients with liver disease of unknown cause, including
those with suspected alcoholic liver disease
All first-degree relatives of patients with
haemochromatosis, known mutation in HFE gene
Patients with conditions that could be a complication
of HFE (diabetes mellitus, atypical arthritis,
cardiomyopathy, erectile dysfunction or chronic fatigue)
15
Test for transferrin

saturation and serum ferritin
concentration. If fasting
transferrin saturation >45%
or fasting ferritin >250 g/L
on more than one occasion,
test for HFE mutations (II,A).
If HFE mutation identified,
discuss options for genetic
testing and referral for
genetic counselling of at-risk
family.
Children of C282Y
heterozygotes should only
be tested if the other parent
has the C282Y mutation.
Testing children in affected
families is generally not
recommended until age
18 years unless symptomatic.
Other first-degree relatives of
C282Y heterozygotes should
be tested with iron studies.
If these are positive, discuss
genetic testing and referral
for genetic counselling.
16

8th edition
Who is at risk?
How often?
References
Mean corpuscular
volume, mean corpuscular
haemoglobin, ferritin
Test couple
prior to
pregnancy or
in first trimester
70, 71
Haemoglobinopathies and thalassaemias
Increased risk
People from any of the following ethnic backgrounds:
Southern European, African (including Americas
and Caribbean), Middle Eastern, Chinese, Indian
subcontinent, Central and South East Asian, Pacific
Islander, New Zealand Maori, South American and
some northern Western Australian and Northern
Territory Indigenous communities
Haemoglobin
electrophoresis
(III,B)
Seek advice from
haematology or
genetic services about
deoxyribonucleic acid (DNA)
testing especially for alphathalassaemia carriers
Fragile X syndrome
Increased risk
Children or adults of either sex with one or more of the
following features:
developmental delay including intellectual disability of
unknown cause
autistic-like features
attention deficit hyperactivity disorder
Karyotype/comparative
genomic hybridisation by
microarray and DNA test for
fragile X
Refer to genetic services
for genetic counselling and
testing at-risk family (I,A)
Any age for

diagnosis
73, 74
Prior to
pregnancy
to ascertain
reproductive
risk
speech and language problems

social and emotional problems, such as aggression or
shyness
a female with a history of primary ovarian insufficiency
or premature menopause (age <40 years)
(IV,B)
72, 75
adults with ataxia, balance problems and Parkinsonism
(IV,A)
76
relative with a fragile X mutation

* First trimester Down syndrome screening:
free beta human chorionic gonadotrophin (HCG), pregnancy associated plasma protein at 1012 weeks
(this also provides risk for trisomy 18, Edwards syndrome)
nuchal translucency screen at 11 weeks 3 days13 weeks 6 days.
Second trimester serum screening:
beta HCG, unconjugated oestriol, alpha-fetoprotein and inhibin A ideally at 1517 weeks; also gives risk
for Edward syndrome and NTDs.

8th edition
3. Preventive activities in children and young people

Early intervention
Prevention and promotion in the early years, from conception to age 5 years, is important for an individuals lifelong
health and wellbeing.77 It may also be an opportunity to redress health inequalities.78, 79 In adolescence, neurodevelopmental studies support the value of early intervention to prevent ongoing harm.80
Many infants and children visit their GP frequently and adolescents visit at least once a year.81 This frequent contact
provides opportunities for disease prevention and health promotion.
Evidence provides moderate support for the hypothesis that accessible, family-centred, continuous,
comprehensive, coordinated, compassionate and culturally effective care improves health outcomes for children
with special healthcare needs.82 There is also evidence that supports the beneficial impact of similar care for
children without special healthcare needs.83
There is little Australian research investigating interventions based in general practice. Recommendations in this
section are largely drawn from expert consensus and parental values.
Health inequity
Compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander children are three times more likely to
die before their first birthday, five times more likely to succumb to sudden infant death syndrome (SIDS), twice as likely
to be born premature or with low birthweight, and nearly four times as likely to be hospitalised with respiratory infection.
Indigenous Australian mothers are eight times more likely than non-Indigenous mothers to receive inadequate antenatal
care and rates of breastfeeding are lower in Indigenous than non-Indigenous communities.84
There is a socioeconomic gradient in the health of Australian children and young people, both Indigenous and nonIndigenous, which has an impact that is both immediate and lifelong. There are large numbers of vulnerable children in
the mid-socioeconomic range of the population and it is the size of this group that justifies universal intervention. On the
other hand, the magnitude of the ill-health experienced by the smaller number at the bottom of the spectrum justifies
targeted intervention. Michael Marmot has attempted to resolve this tension by arguing for proportionate universalism.78
Maternal smoking during pregnancy is more prevalent among women of lower socioeconomic status (SES) and single
mothers, and is strongly associated with low birthweight. Mothers from lower socioeconomic backgrounds have
fewer and less regular antenatal visits. Lower rates of breastfeeding and shorter duration of breastfeeding have been
reported for mothers in a variety of disadvantaged backgrounds including single, low income, migrant, unemployed
families, poorly educated parents and disadvantaged communities. Higher mortality rates in infancy and childhood
including deaths from neonatal hypoxia, SIDS, prematurity-related disorders, and accidental and non-accidental injury
are reported for lower socioeconomic children and children living in disadvantaged neighbourhoods.84 Health inequity
present at school entry gets worse thereafter. The Australian data was summarised in Alan Hayes in 2011.79
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8th edition
Table 3.1 Age-related health checks in children and young people

Age
Neonatal
Vitamin K and immunisation as per the Australian Government Department of Health and Ageing
Australian Immunisation Handbook at www.immunise.health.gov.au (A)
References
Assessment
Metabolic screen (IV,B)
85
Nutrition assessment: review feeding method. Support and appropriately promote breastfeeding
(C) (see Table 3.3 comment a). New NHMRC guidelines expected in 2012
86
Universal hearing assessment see www.health.nsw.gov.au/initiatives/swish/index.asp and

www.aussiedeafkids.org.au/newborn-hearing-screening.html
Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comment b)
87
Identify family strengths, elicit concerns and promote parental confidence, competence and mental
health (C)
88
Preventive counselling and advice

Injury prevention: promote safety from accidental and non-accidental injury. This includes the risks
to baby of passive smoking, SIDS and UV exposure (III,B)
87
Settling (Practice Point)

Maternal health (Practice Point)
2, 4, 6
months
Immunisation as per the Australian Government Department of Health and Ageing Australian
Immunisation Handbook at www.immunise.health.gov.au (A)
Assessment
Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comment b)
87
Nutrition assessment: promote breastfeeding appropriately. Introduction of solids: be aware of

conflicting expert advice concerning the best age at which to introduce solids (B) (see Table 3.3
comment a) New NHMRC guidelines expected in 2012
86, 89
Developmental progress including vision and hearing (see Table 3.3 comment c)
88
Quality of childparent relationship (C)
88, 90
When the baby is presented as a problem assess parental mental health, family functioning
(including the possibility of domestic violence) and social support (C) (see Table 3.3 comment d)
91
Encourage discussion related to physical activity recommendations (B) (see Table 3.3 comment e)
Injury prevention promote safety from accidental and non-accidental injury, includes the risks to
baby of passive smoking, SIDS, UV exposure, water, home environment (III,B)
87, 92, 93
Settling (Practice Point)

Maternal health (Practice Point)
Teething (Practice Point)
Play (Practice Point)
12 & 18
months
Assessment
Lift the lip dental check (C) (see Table 3.3 comment f)
Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 2012
94, 95
Risk of iron depletion and vitamin D deficiency (C)
86, 91
96, 97
Family functioning, dysfunction (including domestic violence) and the social environment (C)
(see Table 3.3 comments h and i)
88, 90

Social and emotional wellbeing (Practice Point)
Toilet training (Practice Point)
Behaviour and behaviour management techniques (Practice Point)
88, 90

8th edition
2 years
19
Assessment
Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comments b and g)
87
94, 95
86, 91
Emerging behavioural or emotional problems (C)

When the child presents with behavioural or emotional problems consider family functioning
(including the possibility of domestic violence) and the family environment more generally (C)
(Practice Point explanatory comments h and i)
88, 90

Injury prevention (III,B)
3 years
Sun protection (Practice Point)
87, 92, 93
Social and emotional wellbeing (C)
88, 90
Assessment
Check vision (B) (see Table 3.3 comment j)
98
The Universal Child Health Check at age 3 years will replace the current Healthy Kids check at age
4 years. To be introduced by the Australian Government in 2013. Details not available at the time of
publication.
4 years
Healthy Kids Check see Table 3.3 comment k
99102
Assessment
Physical assessment (B) (see Table 3.3 comment k)
Also recommended
Developmental and emotional progress (see Table 3.3 comment c)
94, 95
86, 91
Assess the quality of family functioning when there are emotional or behavioural problems (C)
(see Table 3.3 comments h and i)
88, 90

Injury prevention (III,B)
92, 93
Sun protection (Practice Point)

88, 90
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8th edition
Age
613
years
Assessment
References
Growth velocities including BMI opportunistically (B)
103
Discussion relating to progress at school (C)
88
Lift the lip dental check (C) (see Table 3.3 comment f). Encourage regular dental reviews
94, 95
86, 91
Family functioning and family environment (C) (see Table 3.3 comments h and i)
88, 90
Anticipate and look for emerging behavioural or emotional problems (C)
88, 90

Injury prevention (II)
92, 93
Sun protection
1419
years
88, 90
Assessment
Growth velocities including BMI opportunistically (B) (see Table 3.3 comment l)
103, 104
86, 91
Screen sexually active young people for chlamydia (Section 6.2.1: Chlamydia and other STIs)
Screening of adolescents (age 1218 years) for major depressive disorder when systems are in
place to ensure accurate diagnosis, psychotherapy (cognitivebehavioural or interpersonal), and
follow-up (B) (see Table 3.3 comment m)
105

Injury prevention harm minimisation (C) (see Table 3.3 comment n)
88, 92, 93
Sun protection
Social and emotional wellbeing (II,C)
88, 90
Oral health
94, 95
Advocate for models of care that facilitate the transition of young people with chronic disease or
disability from tertiary paediatric care to effective primary care with access to adult specialist care

8th edition
Table 3.2 Age-related physical assessment in children and young people

Age
Required physical assessment
Neonatal
Weight
Length
Head circumference
Head shape, including fontanelle
Mouth/palate, facies and ears
Eyes: observation, appearance and red reflexes
Neurological and developmental status, including responsiveness and tone
Cardiovascular status
Umbilicus
Skin
Femoral pulse (for radio-femoral delay)
Hips (Barlow and Ortolani), limbs, joints, hands (palmar creases), feet (for talipes)
Genitalia, testes, anal region
Any parental concerns?
2, 4 & 6 months
Weight
Length
Head circumference
Eyes: observation, fixation and following
Cardiovascular status
Umbilicus
Skin
Femoral pulse
Hips, limbs, joints
Genitalia, testes, anal region
Oral health, lift the lip from age 6 months
Developmental progress
12 & 18 months
Weight velocity
Height velocity
Head circumference velocity
Eyes and vision: observation, fixation and following, corneal light reflex
Testes
Oral health, lift the lip
2 years
Weight velocity
Length velocity
Head circumference velocity
Evaluate gait
Oral health, lift the lip
Assess development and behaviour
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8th edition
Age
Required physical assessment
3 years
Vision screening
The Universal Child Health Check at age 3 years will replace the current Healthy Kids check at age 4 years.
To be introduced by the Australian Government in 2013. Details not available at the time of publication.
4 years
As outlined by the Health Kids Check:

height and weight (plot and interpret growth curve/calculate BMI)
eyesight
hearing
oral health (teeth and gums)
toileting
allergies.
613 years
Weight and height (plot and interpret growth curve and calculate BMI)
1419 years
Weight and height (plot and interpret growth curve and calculate BMI)
Table 3.3 Explanatory notes for Practice Points

Practice
Point
Comment
The Australasian Society of Clinical Immunology and Allergy (ASCIA) issued a position paper (2008) that supports
the introduction of solids that the family usually eats after 4 months regardless of whether the food is thought
to be highly allergenic89 The ASCIA position is in conflict with the current policy of the RACGP on breastfeeding,
based on the NHMRC guideline,86 which recommends exclusive breastfeeding until age 6 months. This
uncertainty merits frank discussion.
Physical exam:
complete the Child Health Record (also known as the Parent Held Record), which is given at birth87
see outline in Table 3.2 Age-related physical assessment in children and young people.
Note: Parents value reviewing completed growth charts. Velocities are more important than the centile position of
single measurements. Multiple measurements have the further advantage of allowing inaccurate measurements to
become evident as outliers.
Evidence continues to build that early intervention can counteract biological and environmental disadvantage and
set children on a more positive developmental trajectory.106
Early intervention presupposes early detection. Prior to age 3 years the rate of attaining developmental milestones
varies so much that the simple application of screening tools would excessively detect developmental delay
(false positive). This risk is reduced after age 3 years.
In the earliest years, guides to developmental progress can be used to initiate an ongoing conversation with
parents to elicit their concerns about their childs progress. Asking repeatedly should help reluctant parents gain
confidence in their observations and facilitate their willingness to share concerns. The value of such discussions is
clear; children with disabilities are 11 times more likely to be enrolled in needed interventions.107
There is little evidence available; however, early detection is known to help reduce disability in some instances,
and also allows for referral to community services, which can potentially decrease family stress.
Developmental milestone assessments are outlined in the Child Health Record, which is provided at birth.
Acknowledging that parents are the best source of information about their own children, a parent-completed
screening tool, such as the Parent Evaluation of Developmental Status (PEDS), can be used to identify any
concerns about their childs development. The information gathered helps the GP gain a better understanding of
the progress of each child. Further information on the PEDS questionnaire can be accessed at www.rch.org.au/
ccch/resources_and_publications/Monitoring_Child_Development/
Prompts to assist assessment of development include:
Learn the Signs Act Early at www.cdc.gov/ncbddd/actearly/index.html
Red Flags Early Intervention Guide at www.health.qld.gov.au/rch/professionals/brochures/red-flag.pdf
See also Appendix 2. Further information on the Ages and Stages Questionnaire is at http://agesandstages.com

8th edition
23
At present there is insufficient evidence for either benefit or harm in screening for postnatal depression (PND).
However, PND is known to have an unfavourable impact on the quality of attachment and family functioning.
Further, there are evidence-based interventions for both PND108 and for improving the quality of motherinfant
interaction adversely affected by PND.109, 110
Physical activity recommendations for children aged 05 years

Being physically active every day is important for the healthy growth and development of infants, toddlers and
preschoolers.
For infants (birth to 1 year) physical activity particularly supervised floor-based play in safe environments
should be encouraged from birth.
Before infants begin to crawl, encourage them to be physically active by reaching and grasping; pulling and
pushing; moving their head, body and limbs during daily routines and during supervised floor play, including
tummy time. Once infants are mobile, encourage them to be as active as possible in a safe, supervised and
nurturing play environment.
Toddlers (age 13 years) and preschoolers (age 35 years) should be physically active every day for at least
3 hours, spread throughout the day.
Young children dont need to do their 3 hours of physical activity all at once. It can be accumulated throughout
the day and can include light activity such as standing up, moving around and playing, as well as more vigorous
activity like running and jumping. Active play is the best way for young children to be physically active.
Children aged younger than 2 years should not spend any time watching television or using other electronic
media (DVDs, computer and other electronic games) and for children aged 25 years these activities should be
limited to less than 1 hour per day.
Watching television and DVDs and playing computer games usually involve sitting for long periods time that
could be spent playing active games or interacting with others.
Infants, toddlers and preschoolers should not be sedentary, restrained or kept inactive for more than 1 hour at a
time, with the exception of sleeping.
Physical activity recommendations for children aged 512 years
A combination of moderate and vigorous activities for at least 60 minutes a day is recommended. Examples of
moderate activities are a brisk walk, a bike ride or any sort of active play.
More vigorous activities will make kids huff and puff.
Physical activity recommendations for young people aged 1218 years
At least 60 minutes of physical activity every day is recommended. This can be built up throughout the day with
a variety of activities.
Physical activity should be done at moderate to vigorous intensity.
Lift the lip screening tool for the prevention and early detection of tooth decay in children:
complete and also teach parents to simply lift the top lip of child, looking for signs of tooth decay (e.g. white
lines on top of teeth below gumline or discolouration of the teeth that cannot be brushed off). Encourage
parents to complete once a month
encourage dental hygiene twice a day: no toothpaste under 17 months and low fluoride toothpaste up to age 5
years
encourage dental visits annually after age 12 months.
See also NHMRC research at www.nhmrc.gov.au/national_register_public_health_research/29331 and
Section 11: Oral hygiene.
The American Academy of Paediatrics has recommended the annual plotting of BMI for all patients aged 2 years
and older, and parent-held records produced by Australian jurisdictions follow this recommendation. This is not
supported by the United States Preventive Services Task Force (USPSTF). There is potential for causing harm
by either inappropriate diagnosis of overweight or inappropriate reassurance of healthy weight. The risk will
be minimised if clinicians remember that in the preschool years, small errors in measuring either height/length or
weight cause large errors in the position of the calculated BMI on the BMI centile chart. This is because centile
lines are crowded together in the preschool ages.
An Australian RCT demonstrated that a coordinated cross agency system of parenting support, which included
general practice, produced meaningful effects at the population level.90
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8th edition
Practice
Point
Comment
For pre-school children, family support and parenting programs continue to be the most effective method of
preventing the onset of emotional and behavioural problems, which predispose to mental illness in later childhood
and adolescence.88, 106
The USPSTF concludes with moderate certainty that vision screening for all children at least once between
the ages of 35 years to detect the presence of amblyopia or its risk factors has a moderate net benefit.98 The
USPSTF concludes that the benefits of vision screening for children aged <3 years are uncertain and that the
balance of benefits and harms cannot be determined for this age group.
Various screening tests that are feasible in primary care are used to identify visual impairment among children.
These include visual acuity tests, stereoacuity tests, the coveruncover test, and the Hirschberg light reflex test
(for ocular alignment/strabismus), as well as the use of autorefractors (automated optical instruments that detect
refractive errors) and photoscreeners (instruments that detect amblyogenic risk factors and refractive errors).
The Universal Child Health Check at age 3 years will replace the current Healthy Kids Check at age 4 years this
is to be introduced by the Australian Government in 2013 (details not available at the time of publication).
Australian Government Department of Health and Ageing Medicare Benefits Schedule (MBS) Primary Care Items:
Healthy Kids Check for children aged at least 3 years and less than 5 years, who have received or who are
receiving their age 4-year immunisation
once only to an eligible patient
the Healthy Kids Check is an assessment of a patients physical health, general wellbeing and development
with the purpose of initiating medical interventions as appropriate.
The Healthy Kids Check must include the following basic physical examinations and assessments:
a. height and weight (plot and interpret growth curve/calculate BMI)
b. eyesight
c. hearing
d. oral health (teeth and gums)
e. toileting
f. allergies.
The medical practitioner is required to note if a copy of the departments publication Get Set 4 Life habits for
healthy kids has been provided to the patients parent(s)/guardian at www.health.gov.au/internet/main/publishing.
nsf/content/47B8A7F882590379CA25759B001EE259/$File/GetSet4LifeBrochure.pdf
The medical practitioner is also required to note that the age 4-year immunisation has been given (including
evidence provided).
See also www.health.gov.au/internet/main/publishing.nsf/Content/Health_Kids_Check_Factsheet
The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or
refer them to comprehensive, intensive behavioural interventions to promote improvement in weight status (B).103
There is a moderate net benefit for screening children aged 618 years.
As a screening tool, BMI is an acceptable measure for identifying children and adolescents with excess
weight.103
The definitions used by the USPSTF have changed since the 2005 report. Overweight is now defined as having
a BMI between the 85th and 94th percentiles for the individuals age and gender, and obesity is defined as
having a BMI at 95th percentile for age and gender. BMI-for-age percentile is not a direct measure of adiposity,
but it correlates fairly well with percentile rankings of directly measured per cent body fat (with correlations
generally between 0.78 and 0.88) in children. Because BMI changes with age, percentile scores based on agespecific and gender-specific norms are used to monitor growth.
National Institute of Clinical Excellence (also known as NICE)104
BMI (adjusted for age and gender) is recommended as a practical estimate of overweight in children and young
people, but needs to be interpreted with caution because it is not a direct measure of adiposity.
Waist circumference is not recommended as a routine measure, but may be used to give additional information
on the risk of developing other long-term health problems.
Bio-impedance is not recommended as a substitute for BMI as a measure of general adiposity.

8th edition
25
Mental, emotional, behavioural disorder in Australian young people

Fifty per cent of adult disorders have onset by age 14 years.
Fourteen per cent to 18% of children and young people experience mental health problems of clinical
significance.
Depression and coping with stress are priorities for:
16% of those aged 1114 years
21% of those aged 1519 years.111
The USPSTF recommends screening of adolescents (aged 1218 years) for major depressive disorder when
systems are in place to ensure accurate diagnosis, psychotherapy (cognitivebehavioural or interpersonal), and
follow-up105 (B).
Risk factors for major depressive disorder include parental depression, having comorbid mental health or
chronic medical conditions, and having experienced a major negative life event.105
Promoting health and minimising harm is a whole-of-community opportunity and responsibility. Celebrating
strengths, explaining confidentiality (including its limits) and using the HEADSS framework (below) to explore
with young people the context in which they live are strategies likely to improve the clinicians capacity to
promote health and minimise morbidity112 (C).
Home
Education/Employment
Activities
Drugs
Sexuality
Suicide
Young people who present frequently are at higher risk of having a mental health problem.113
Provide messages that encourage delay in initiation of potentially risky behaviours, and, at the same time,
promote risk-reduction strategies if adolescents choose to engage or are already engaging in the behaviour.
Use principles of motivational interviewing in the assessment and discussion of risky health behaviours with
adolescent patients (including safe practice for the sexually active).
Be familiar with the resources in the community that provide harm reduction programs for substance abuse,
pregnancy prevention and injury prevention.
Be familiar with resources in the community that provide parenting skills training for parents of young people.
Advocate for the introduction, further development and evaluation of evidence-based prevention and treatment
programs that use a harm reduction philosophy in schools and communities (C).
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4. Preventive activities in middle age

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054 5559 6064 6569
7079
80
The recommended specific activities for low-risk patients in the 4564 years age group are listed below. Patients
should be offered these opportunistically, or at 25-year intervals.
Planned health checks in middle-aged adults have been demonstrated to improve the frequency of management
of smoking, nutrition, alcohol and physical activity (SNAP) behavioural risk factors; screening for cervical and CRC
and hyperlipidaemia, in general practice.16, 114, 115 There is also evidence that Indigenous health checks improve early
detection of diabetes and provision of preventive care.116 However, there is mixed evidence for the effectiveness
of interventions to address multiple risk factors.117 These checks may be facilitated by involvement of practice
nurses.118120 Interventions should be tailored to level of risk and use of the 5As framework (Ask, Assess, Advise,
Assist and Agree, Arrange follow-up) is recommended as a guide to their delivery in primary healthcare.121
Table 4.1 Age-related health checks in middle age

Age
4549
years
Ask about:
Pages
SNAP and readiness to change
4049
risk of diabetes using Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK)
5557 Appendix 4
depression in increased risk groups (past history, physical illness, other mental problems, etc.)
7374
risk factors for osteoporosis
8283
skin cancer.
6062
Measure:
weight, height (calculate BMI) and waist circumference
4344
BP
5153
fasting lipids
5355
fasting blood glucose in patients at high risk of diabetes.
5557
Perform:
Pap test every 2 years
6365
mammography if family history indicates high risk.
6567
Calculate:
absolute cardiovascular risk.
Appendix 5

8th edition
Age
5064
years
Ask about:
27
Pages
SNAP and readiness to change
4049
risk of diabetes using AUSDRISK
5557 Appendix 4
depression in increased risk groups (past history, physical illness, other mental problems, etc.)
7374
risk factors for osteoporosis
8283
skin cancer.
6062
Measure:
weight, height (calculate BMI) and waist circumference
4344
BP
5153
fasting lipids
5355
fasting blood glucose in patients at high risk of diabetes
5557
urinalysis for protein.
5859
Perform:
Pap test every 2 years
6365
CRC screening with faecal occult blood testing (FOBT) at least every 2 years
6870
mammography every 2 years
6567
vaccination for dTpa. Consider influenza and pneumococcal vaccination if high risk.
3536
Calculate:
absolute cardiovascular risk.
Appendix 5
Table 4.2 Preventive interventions in middle age

Intervention
Technique
References
Health education
Tailor health advice or education to the patients risk, stage of change and health
literacy (see Section II Patient education and health literacy).
36
Practice
organisation
Use clinical audit to identify patients who have not had preventive activity. Recall to
practice or opportunistically arrange a health check.
122
Implementation
Health inequity
Individual behavioural counselling is most likely to be effective for patients from disadvantaged backgrounds if linked
to community resources and if financial and access barriers are addressed. Provider attitudes are also important in
building self-efficacy among patients from these groups. Aboriginal and Torres Strait Islander and low SES patients
have higher risk of disease, but are less likely to be offered preventive interventions.
Strategies
Strategies to increase screening and effective motivational and behavioural interventions in this group are discussed
in the RACGP green book.
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8th edition
5. Preventive activities in older age

Older people are at increased risk of multiple chronic conditions that may impair their function and quality of life.
Those living alone are particularly vulnerable. Their health problems may be exacerbated by poor nutrition, lack of
physical activity and lack of sun exposure.
Older people may rely on the help and support of family and carers. Carers, particularly carers for people with
dementia or depression, are at risk of depression, anxiety, emotional distress, loneliness and isolation but their
healthcare needs are often overlooked.123127 Their need for support should be assessed when possible128 (C).
Carer support resources are helpful for carer wellbeing and may delay the need for the older person to be relocated
to a residential facility.123, 129131 People should be advised to plan for their care as they get older. This includes
organising wills, power of attorney and an advance care plan.
Medication-related problems may cause unnecessary hospital admission, adverse drug reactions and other
adverse outcomes for people living in the community.132 GPs should review medications in older people, particularly
for vulnerable groups. Vulnerability factors include:
recent discharge from hospital
high-risk drug groups (e.g. anticoagulants)
confusion/cognitive impairment or dementia
history of falls
currently taking five or more regular medications
target disease states where medication management is an important process of care (CKD, congestive cardiac
failure)133
multiple chronic medical problems
regular use of alcohol
previous adverse drug reaction.
GPs may consider a pharmacist medication review. The most successful interventions have been delivered by
small numbers of pharmacists working in close liaison with primary care doctors (III,C).134 The review should include
consideration of the need for each medication; issues around patient compliance and understanding of the medication;
screening for side effects, particularly falls and cognitive impairment; and consideration of the use of aids such as dosette
boxes and Webster packaging. A review of the combined anticholinergic load and sedative load of the medications may
also be done, as anticholinergic and sedative loads increase the rate of confusion and other adverse side effects.
5.1 Immunisation
Immunisation is recommended for adults aged 65 years and over, according to the Australian Government Department
of Health and Ageing Australian Immunisation Handbook.
Table 5.1 Immunisation: preventive interventions in older age

Intervention
Technique
References
Vaccination:
influenza
Annual influenza vaccination in the pre-flu season months (III,C).
135
Vaccination:
pneumococcal
Pneumococcal polysaccharide vaccination (23vPPV) is recommended for the

prevention of invasive pneumococcal disease (II,B).
136
Vaccination should be done opportunistically. One dose is currently recommended

except for those who have a condition that predisposes them to an increased risk of
invasive pneumococcal disease.
See http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/
pneumo23-atagi-statement-cnt.htm
Vaccination:
herpes zoster
A single dose of zoster vaccine is recommended for adults aged 60 years and over (II,B)
See also Section 6.1: Immunisation.
137
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8th edition
5.2 Falls and physical activity

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Advice about moderate physical activity is recommended for all older people138, 139 (A).
Approximately 30% of people aged 65 years or older report one or more falls in the last 12 months.140 For the
older person, physical activity provides many benefits, as well as minimising some of the limitations of later life (e.g.
reduced mobility, tendency to fall and reduced interaction with the environment).141
Table 5.2.1 Falls: identifying risks

Who is at risk of falls?
How often?
References
Average risk
Screen for falls and risk factors

for falls* (I,A)
Every 12 months
139, 142, 143
Screen for risk factors and

involve in preventive activities*
(I,A)
Every 6 months
140, 142
All people aged 65 years or more

Moderately high risk
Older people presenting with one or more
falls, who report recurrent falls or with
multiple risk factors (see Table 5.2.2)
* If the person has inadequate sun exposure, Vitamin D supplement should be recommended to reduce the risk of fracture.144
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8th edition
Table 5.2.2 Falls: preventive interventions

Intervention
Technique
References
Screening for falls

risk
Ask the following three screening questions:
140, 142,
145150
1. Have you had two or more falls in the past 12 months?

2. Are you presenting following a fall?
3. Are you having difficulty with walking or balance?
If the answers to any of these are positive:
obtain relevant medical history, complete a physical examination, and perform
cognitive and functional assessments
determine multifactorial fall risk:
151
history of falls
multiple medications, and specific medications (e.g. psychotropic medications
and opiate-containing analgesic agents)
impaired gait, balance and mobility
impaired visual acuity, including cataracts
issues with bifocal or multifocal spectacle use
reduced visual fields
other neurological impairment
muscle weakness
cardiac dysrhythmias
postural hypotension
foot pain and deformities and unsafe footwear
home hazards
vitamin D deficiency.
There are many fall risk-assessment tools. However, reports from researchers are
variable, so no single tool can be recommended for implementation in all settings
or for all subpopulations within each setting. A quick screening tool is the timed up
and go test (TUGT), which involves looking for unsteadiness as the older person
gets up from a chair without using his or her arms, walks 3 metres and returns. The
usefulness of timing this test as a predictor of falls has been questioned.
152
Simple alternatives to the TUGT are the repeated chair standing test and the
alternate step test. The repeated chair standing test measures how quickly an older
person can rise from a chair five times without using the arms. A time of >12 seconds
indicates an increased fall risk. The alternate step test measures how quickly an
older person can alternate steps (left, right, left, etc.) onto an 18 cm high step a total
of eight times. A time >10 seconds indicates an increased fall risk. The Quickscreen
assessment tool, developed and validated for use in an Australian population,
includes these tests as well as simple assessments of medication use, vision,
sensation and balance.
153
See also Section 13: Urinary incontinence
154

8th edition
Falls risk reduction
Prescribe or refer for a home-based exercise program and/or encourage

participation in a community-based exercise program. In either case, exercise
for preventing falls needs to include medium-intensity to high-intensity balance
training (i.e. exercises must be undertaken while standing and challenge balance),
and be of long duration, preferably ongoing. Exercise programs targeting nonEnglish speaking patients may need to address cultural norms about appropriate
levels of physical activity.
31
155161
162
163
Physical activity recommendations for older adults from the American College of
Sports Medicine and American Heart Association are:
do moderately intense aerobic exercise 30 min/day, 5 days/week or vigorous
aerobic exercise 20 min/day, 3 days/week and
do 810 muscle strength training exercises, 1015 repetitions of each exercise
23 times/week and
if at risk of falling, perform balance exercises and have a physical activity plan.
Review medications and discontinue centrally acting medications where clinically
appropriate.
Consider prescribing vitamin D for people with vitamin D levels <50 nmol/L for
older people living in the community (III,C) and consider routinely prescribing
vitamin D (unless contraindicated) for all older people living in residential aged care
(I,B), as routine sun exposure in residential aged care may not be feasible.
164
See also Section 14: Osteoporosis.

Refer people with painful feet or foot deformities to podiatry for intervention.
Provide advice on the dangers of bifocal and multifocal glasses when walking
outdoors (as these blur ground-level obstacles) and recommend the wearing of
single lens glasses when outdoors.
Identify cataracts and refer for cataract extraction.
Refer people with a history of recent falls for an occupational therapy home
assessment.
5.3 Visual and hearing impairment

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
Visual acuity should be assessed from age 65 years using the Snellen chart (B) in those with symptoms or who
request it. There is no evidence that screening of asymptomatic older people results in improved vision.165
Hearing loss is a common problem among older individuals and is associated with significant physical, functional
and mental health consequences. Annual questioning about hearing impairment is recommended with people aged
65 years and over (B).
In some states and territories, there are legal requirements for annual assessment (e.g. driving over age 70 years).166
Eye disease and visual impairment increase threefold with each decade of life after age 40 years. They are often
accompanied by isolation, depression and poorer social relationships, and are strongly associated with falls and hip
fractures.167 It should be determined whether the patient is wearing an up-to-date prescription, and whether there
is a possibility of falls because they are no longer capable of managing a bifocal, trifocal or multifocal prescription.
People at greater risk of visual loss are older people and those with diabetes and a family history of vision
impairment. Cataracts are the most common eye disease (42% of cases of visual impairment), followed by agerelated macular degeneration (AMD) (30%), diabetic retinopathy and glaucoma. The leading causes of blindness in
those aged >65 years are AMD (55%), glaucoma (16%) and diabetic retinopathy (16%).168
80
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8th edition
Table 5.3.1 Visual and hearing impairment: identifying risks

Who is at higher risk of hearing loss?
How often?
References
People 65 years
Screen for hearing impairment

(II,B)
Every 12 months
169
Table 5.3.2 Visual and hearing impairment: preventive interventions

Intervention
Technique
References
Visual
impairment: case
finding
Use a Snellen chart to screen for visual impairment in the elderly if requested or if
indicated by symptoms. There is no evidence that screening asymptomatic older
people results in improvements in vision.
165, 170
See also Section 12: Glaucoma.

Hearing
impairment
screening
A whispered voice out of field of vision (at 0.5 metre) or finger rub at 5 cm has a high
sensitivity for hearing loss, as does a single question about hearing difficulty.
169, 171
5.4 Dementia
With people aged over 65 years, clinicians should be alert to the symptoms and signs of dementia. These may
be detected opportunistically and assessed using questions addressed to the person and/or their carer (C).
Depression and dementia may co-exist. When a person has dementia, adequate support is required for the person,
carer and family. Counselling and education are important. Management priorities will vary from patient to patient,
but there may be a need to consider medical management of dementia, behaviour and comorbidity, legal and
financial planning, driving and advance care planning.172
Table 5.4.1 Dementia: identifying risks

Who is at risk?
How often?
References
Average risk
No evidence of benefit from

screening (II,C)
n/a
173, 174
Case finding and early

intervention (III,C)
n/a
175177
Those without symptoms

Moderate risk
Risk increases with increasing age
A family history of Alzheimer disease
People with history of repeated head trauma
178
People with Down syndrome

Those with elevated cardiovascular risk (heart
disease, stroke, hypertension, obesity, diabetes,
elevated homocysteine, elevated cholesterol)
Those with depression or a history of depression
Those with symptoms (see Table 5.4.2)
179184
177

8th edition
33
Table 5.4.2 Dementia: preventive interventions

Intervention
Technique
References
Case finding and

confirmation
Ask How is your memory? and obtain information from others who know the
person (e.g. repeating questions, forgetting conversations, double buying, unpaid
bills, social withdrawal).
185
Other symptoms may include a decline in thinking, planning and organising and
reduced emotional control or change in social behaviour affecting daily activities.
Not everyone with dementia has memory problems as an initial symptom (C). Other
clues are missed appointments (receptionist often knows), change in compliance
with medications and observable deterioration in grooming, dressing.
186, 187
Over several consultations, obtain the history from the person and family/carer, and
perform a comprehensive physical examination. Undertake cognitive assessment
using:
Mini-Mental State Examination (MMSE) at www.minimental.com
General Practitioner Assessment of Cognition at www.gpcog.com.au
186
clock drawing test
188
R
owland Universal Dementia Assessment Scale at www.fightdementia.org.au/
understanding-dementia/rowland-universal-dementia-assessment-scale.aspx is
a multicultural cognitive assessment scale that has been used to detect dementia
across cultures.
189
The MMSE is the most widely used and evaluated scale.

Assess functional status. The Instrumental Activities of Daily Living at
www.abramsoncenter.org/PRI/documents/IADL.pdf assessment tool may be used.
All screening instruments used to assess dementia in general practice have high
rates of overdiagnosis (false positives) and underdiagnosis (false negatives), so the
full clinical presentation needs to be taken into account.
Early intervention
and prevention
Evidence is growing that attention to cardiovascular risk factors may improve

cognitive function and/or reduce dementia risk. A 2012 review has suggested that
there is sufficient evidence now for clinicians to recommend the following strategies
for early intervention and prevention of dementia: increased physical activity
(e.g. 150 minutes per week of moderate-intensity walking or equivalent), social
engagement (increased number of social activities per week) and cognitive training
and rehabilitation.
See also Section 7: Prevention of chronic disease, Section 8: Prevention of vascular
and metabolic disease and Section 10: Psychosocial
179184
190
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6. Communicable diseases
GPs have an important role in the prevention and management of communicable diseases. This includes advice on
prevention, immunisation, early detection and treatment.
Updates on communicable diseases and notification requirements are available from the Australian Department of
Health and Ageing at www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-nndss-casedefs-distype.htm
GPs laboratories and hospitals are required by law to notify particular infectious diseases to their local or state
public health units (this law overrides all privacy regulations). A list of state-specific notifiable infectious diseases
is also available from state health department websites. This role has become almost completely automated
by pathology laboratories as a result of advances in information technology. The GP may still need to ensure
notification has occurred on occasions where a clinical diagnosis is made, or where clinical information is required.
Please note that varicella and zoster are notifiable diseases with or without the need for pathology testing.
6.1 Immunisation
Age
<2
23
49
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
Immunisation is recommended for all children and adults at particular ages, according to the Australian
Immunisation Handbook (A). GPs should advocate immunisation and counter the common misunderstandings and
antivaccine campaigns.
The National Immunisation Program Schedule (NIPS) lists the recommended funded vaccines. There may be
other vaccines that are not funded but are recommended in the Australian Immunisation Handbook. There may be
variability in vaccines recommended/funded, for example, hepatitis A vaccine (hep A).
Vaccination for special high-risk groups

Adults or children who develop asplenia, HIV infection or a haematological malignancy, or who receive a bone
marrow or other transplant (following recovery), may not be fit for some vaccinations, or may require additional
vaccinations, including the need for repeat vaccinations at http://immunise.health.gov.au
Health inequity
For immunisation to be effective there needs to be high coverage. Thus GPs need to be aware of groups with lower
levels of age-appropriate immunisation including:191
families with young parents under age 25 years192, 193
single-parent families and families with more than one child194
migrant families, particularly in the first years of their arrival in Australia, or if a language other than English is spoken at
home192196
families where the parents are unemployed,191, 195 on low incomes192, 195 or have very high or very low education
levels193, 194, 197
families who move frequently196
Aboriginal children in rural and urban areas.198, 199
For young people with a chronic illness, cost may be a barrier to achieving appropriate immunisation against influenza
and pneumococcal infection.200
65

8th edition
Table 6.1.1 The National Immunisation Program Schedule

Sequence
Age
Vaccine
Birth*
Hepatitis B (hep B)
68 weeks
hep B
DTPa
Haemophilus influenzae type b (Hib)
Inactivated poliomyelitis (IPV)
13-valent pneumococcal (13vPCV)
Rotavirus
4 months
hep B
DTPa
Hib
IPV
13vPCV
Rotavirus
6 months
hep B
DTPa
Hib
IPV
13vPCV
(3)
Rotavirus (Rotateq only)
6 months to <5 years
Influenza (for all Aboriginal and Torres Strait Islander peoples) annually
12 months
hep B (fifth dose for those born <32 weeks or <2000 g birthweight)
Hib
MMR first dose
Meningococcal C (MenCCV)
13vPCV booster for high-risk groups
1218 months
hep A (for Aboriginal and Torres Strait Islander peoples in the Northern Territory,
Queensland, South Australia and Western Australia only)
18 months
MMR and varicella, or MMRV instead of separate varicella at 18 months and MMR
at age 4 years (when available)
1824 months
hep A (for Aboriginal and Torres Strait Islander peoples in the Northern Territory,
Queensland, South Australia and Western Australia only)
24 months
13vPCV booster (for Aboriginal and Torres Strait Islander children)
4 years
DTPa
IPV
MMR (to be superseded by combined MMRV at 18 months by 2016)
23vPPV (only for high-risk groups )
1&2
1213 years
hep B (2 adult doses for those not vaccinated against hepatitis B)
Varicella (catch up until all immunised)
1, 2 & 3
HPV (three doses over 6 months, for both sexes catch-up 201315)
15 years
dTpa is the adult/adolescent vaccine
1549 years
Influenza (for all Aboriginal and Torres Strait Islander peoples) annually
23vPPV (only at-risk Aboriginal and Torres Strait Islander peoples)
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8th edition
Sequence
Age
Vaccine
50 years and over
Influenza (Aboriginal and Torres Strait Islander peoples)

23vPPV (Aboriginal and Torres Strait Islander peoples)
65 years and over
Influenza
23vPPV
* hep B vaccine (dose 1 or 0) should be given to all infants within 24 hours of birth ideally, but at most within 7 days of birth. Infants
whose mothers are hepatitis B surface antigen positive should be given hepatitis B immunoglobulin within 12 hours of birth.
Rotavirus vaccines are contraindicated in infants with a history of intussusception (IS), or predisposing abnormality to IS, or severe
combined immunodeficiency. Rotavirus vaccines are time limited and differ in number of doses and timing:
Dose 1 must be given before age 12 weeks (Rotateq) or 14 weeks (Rotarix) or not at all.
Dose 2 must be given before age 24 weeks (Rotarix) or before 28 weeks (Rotateq) or not at all.
Dose 3 ONLY for Rotateq must be given before age 32 weeks or not at all.
MMR dose 2, previously at age 4 years, and separate varicella at 18 months, is to be replaced by combined MMRV at 18 months
and predicted to be available by July 2013.
It is recommended that all people aged 50 years should be given DT. dTpa is preferred instead of DT to protect from pertussis. This
is funded for parents and carers of infants under age 6 months in some states. It can be given regardless of timing of previous DT.
Table 6.1.2 Recommended vaccines in the Australian Immunisation Handbook not in the NIPS
Age
Vaccine
Soon after birth
Bacillus CalmetteGurin (or BCG) (for Aboriginal and Torres Strait Islander peoples in the Northern
Territory, Queensland, and parts of Northern South Australia).
From 6 months
Annual influenza vaccination is recommended for any person aged 6 months where there is a wish to
reduce the likelihood of becoming ill with influenza. Only Influvac or Vaxigrip influenza vaccines are suitable
for use from the age of 6 months.
Under 14 years
Varicella: a second dose improves protection from varicella from 94% to 98%
Parents and
carers of infants
under age 6
months
DTpa is recommended to protect the infant from pertussis. To maximise the protection of infants, the
options are to give before, immediately after, or in the third trimester of pregenancy. The dTpa vaccine can
be given at any time after DT and dTpa may be given again 10 years after previous dTpa. Please refer to
the Australian Immunisation Handbook for details.
50 years
dTpa is preferred to DT
(This booster dose is recommended if no tetanus immunisation was received in the previous 10 years)*
From 60 years
Zoster virus live vaccine (e.g. Zostavax) for prevention of shingles
All healthcare
workers
hep B (and hep A in some jurisdictions)

Annual influenza
dTpa
MMR (if not immune)
Varicella (if not immune)
Men who have

sex with men
hep B and hep A
Injecting drug
users
* It is recommended that all 50-year-olds should be given DT. dTpa is preferred instead of DT to protect from pertussis. This is
funded for parents and carers of infants under age 6 months in some states. It can be given regardless of timing of previous DT.

8th edition
Immunisation information resources include:

the Australian Government Immunisation Handbook is online at http://immunise.health.gov.au
the Australian Childhood Immunisation Register enquiry line is available on telephone 1800 653 809. This phone
number can be used to obtain information on the vaccination history of individuals from birth7 years of age given
since 1 January 1996
the National Centre for Immunisation Research & Surveillance is at www.ncirs.usyd.edu.au
Notification of adverse events

The reporting of adverse events following vaccinations varies geographically. It is possible to report direct to the
Therapeutic Goods Administration from anywhere in Australia by telephoning 1800 044 114, or visiting its website at
www.tga.gov.au/hp/problem-medicine-reporting-reactions.htm
6.2 STIs
STIs are frequently seen in general practice, especially chlamydia, which is typically asymptomatic. It is important to
detect it early in order to minimise potential complications, such as infertility, and to prevent transmission to others.
It may also be appropriate to screen for other STIs. The individuals age and sexual behaviour and community STI
prevalence all influence the level of risk, and should influence the choice of STI screening tests.
Sexual health consultation

Many patients and doctors do not like discussing sexual histories even when the patient is requesting STI testing,
or it is indicated. While taking a sexual history is an important part of the assessment and management of STIs, it
should not be a barrier to offering STI testing. The patient may not disclose the truth to avoid embarrassment.201
A non-judgemental attitude and environment will maximise patient disclosures on sexual matters.202 It is important
to ask open questions and to avoid terms that make assumptions about sexual behaviour or orientation
(e.g. by using the term partner). Issues to cover include current sexual activity, gender and number of partners,
contraception (including use of condoms), immunisation status and other risk factors for blood-borne viruses (such
as injecting drug use, tattooing and piercing). Investigations should be explained, and patients should be counselled
and asked for consent before ordering tests such as HIV or hepatitis C.
Contact tracing is an important part of the management of most STIs, and it is the responsibility of the diagnosing
clinician to facilitate the process of notifying current and past partners. This may be by a direct approach from the
patient or their treating health professional, or by using online partner notification services such as:
www.letthemknow.org.au
www.thedramadownunder.info/notify (for males with male partners)
www.bettertoknow.org.au (for Aboriginal youth).
For more information and to determine how far back to trace see the contact tracing manual at http://ctm.ashm.
org.au/ or contact tracing tool at http://www.stipu.nsw.gov.au/content/Document/GP%20Contact%20Tracing%20
Tool.pdf
In the case of a notifiable condition, the patient should be informed that case notification to public health authorities
will occur. Notification should be made as prescribed by the department of health in your state or territory.
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6.2.1 Chlamydia and other STIs

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Screening for chlamydia infection in all sexually active people aged 1529 years is recommended because of
increased prevalence and risk of complications.203
Younger sexually active youth should not be excluded from case finding, or identifying any safety or abuse issues.
Women with untreated chlamydia infections have a 28% risk of infertility.204 Other STIs to consider screening for
in higher risk individuals are gonorrhoea, HIV and syphilis.205 The risk for gonorrhoea, HIV and syphilis is low for
heterosexuals in all major cities in Australia and New Zealand206 but rates of gonorrhoea and syphilis may be higher in
remote community settings. The individuals age and sexual behaviour and community STI prevalence influence the
level of risk and should guide STI testing recommendations for patients. (Please refer to tables for guidance.)
Men who have sex with men (MSM) should be screened for gonorrhoea, chlamydia, syphilis and HIV every 12 months.
Men who have multiple sexual contacts should be screened more often. Most MSM with STIs have no symptoms.207
Screening for hepatitis C should be provided if the patient is HIV positive or there is a history of injecting drug use.
There is good evidence that all pregnant women at risk should be screened for hepatitis B, HIV and syphilis;205
screen for chlamydia and possibly gonorrhoea if the patient is considered to be particularly at risk.208, 209
Table 6.2.1.1 STIs: identifying risks

Who is at higher risk of infection and
complications?
How often?
References
All sexually active young people aged

1529 years, particularly if:
Urine or genital swab for

chlamydia (II, A)
Every 12 months
203, 210215
under age 20 years
Consider other infections based

on risk assessment such as
gonorrhoea, hepatitis B, syphilis
and HIV
High-risk asymptomatic
Aboriginal or Torres Strait Islander

inconsistent or no condom usage
recent change in sexual partner
A good opportunity
is at same time
as Pap test or
presentation for
other reasons
216
Consider trichomonas in remote

communities (III)
Asymptomatic men who have sex with men

Higher risk in those who:217
have unprotected anal sex
have had >10 partners in past 6 months
participate in group sex or use recreational
drugs during sex
Urine and rectal swab for

chlamydia polymerase chain
reaction (PCR)
Every 12 months
and 36 monthly in
higher risk men
217, 218, 219
If chlamydia infection
found (and treated),
repeating testing
to check for reinfection after 312
months may be
appropriate
220223
Throat and rectal swab for

gonorrhoea PCR (III, B)
Serology for HIV, syphilis and
hepatitis A and B serology if not
vaccinated or immune
Also offer hepatitis A and B
vaccination (III,B)
Sexual contacts from the last 6 months of

infected women and men
Test and treat contacts

presumptively (II,A)
For how far back to trace, see www.stipu.nsw.

gov.au/content/Document/GP%20Contact%20
Tracing%20Tool.pdf
Consider other infections based

on risk assessment such as
gonorrhoea, hepatitis B (if not
vaccinated), syphilis and HIV (III,B)
Low risk heterosexual asymptomatic

requesting STI check-up
Urine PCR or genital swab for

chlamydia, serology for hepatitis
B (if not vaccinated or immune),
syphilis and HIV (III, B)
219

8th edition
39
Table 6.2.1.2 Tests to detect STIs

Test
Technique
Site
References
Nucleic acid
amplification
test (NAAT)
most
commonly by
PCR
Should be (20 mL) first void urine (passed at least 1 hour after last having
urinated (i.e. not midstream) (I,B)
Urine,
endocervix
or vagina
206, 222, 224
PCR endocervical or vaginal swab (patient can self-collect) also possible

in females (I,B)
219
This technique has also been validated for anal or throat swabs:
r ectal swab should be inserted ~3 cm into anus and rotated
(asymptomatic men who have sex with men can be taught to perform
this test themselves, with the aid of a visual diagram. See www.stipu.
nsw.gov.au/icms_docs/117569_Self_Collected_Specimen_Chart.pdf
throat swab should sample the posterior pharyngeal wall and tonsillar
crypts
NAATs are highly sensitive and specific for chlamydia and gonorrhoea
from all specimens. False positive gonorrhoea results can occur,
especially if testing low-risk individuals. However, laboratories usually
perform supplemental assays to confirm results for gonorrhoea.
Gonorrhoea
microscopy,
culture and
sensitivity
(MCS)
Rectal swab should be inserted 3 cm into anus and rotated
225
MCS is of use to guide treatment where resistance to antibiotics is a

problem
Implementation
Chlamydia is the most common and curable STI in Australia. Notification rates per 100 000 have increased from
35.4 in 1993 to 319 in 2010, mostly in those aged 1529 years.226 Estimated infection rates of the sexually active
population in this age group vary from 412%. Young Aboriginal and Torres Strait Islander peoples have the highest
infection rates, which are 1234% in some locations. There is also an increased risk of gonorrhoea and syphilis
among Aboriginal and Torres Strait Islander peoples.
Screening of sexually active women under age 25 years for chlamydia on an annual basis has been shown to halve
the infection and complication rates204, 227 All partners of those infected should be tested and treated presumptively.
A systematic review has shown that providing patient-delivered partner therapy to index cases is more effective in
reducing infection rates than paper-based methods of contact tracing.228 It is important to ensure current sexual
partners are treated simultaneously. Referral to a sexual health clinic may provide improved contact tracing and
should be considered for problematic repeated infections.229
Untreated pregnant women infected with chlamydia have a 2050% chance of infecting their infant at delivery.230
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8th edition
7. Prevention of chronic disease

The SNAP risk factors are common among patients attending general practice.231 They contribute significantly to the
burden of disease, largely due to their effect on the incidence and complications of chronic diseases such as diabetes,
cardiovascular disease (CVD), chronic respiratory disease and some cancers.2, 232 While there is some debate about the
impact and effectiveness of GPs and practice nurses on a patients lifestyle,233235 most accept that GPs and their teams
have a role and can be effective in each of the SNAP lifestyle areas. including smoking,55, 236, 237 hazardous drinking,44, 238
physical activity239241 and dietary change.239, 242
Each of these risk factors may interact with each other throughout the lifecycle and need to be considered together rather
than separately. Behavioural counselling approaches such as motivational interviewing243 may be tailored to the patients
readiness to change their behaviour (see the RACGP green book for more details)244 and should consider the patients
literacy and health literacy.243 The 5As121, 245249 is an internationally accepted framework for organising the assessment and
management of all the behavioural risk factors in primary healthcare. It consists of:
Ask a systematic approach to all patients regarding their smoking, nutrition, alcohol or physical activity, which may occur
opportunistically as they present for other conditions and/or by recall for health checks
Assess assess readiness to change, and dependence (for smoking and alcohol)
Advise provide brief, non-judgemental advice with patient education materials (such as Lifescripts) and work with the
patient to set agreed goals
Assist provide motivational interviewing; refer to telephone support services, group lifestyle programs or individual
providers (e.g. dietitian or exercise physiologist); and consider pharmacotherapy
Arrange regular follow-up visits to monitor maintenance and prevent relapse.
A systematic approach to identifying chronic disease can be more effective as a larger number of eligible subjects are
identified and assisted.244, 250, 251

8th edition
Health inequity
Disadvantaged people (low incomes and/or education) have higher rates of smoking and alcohol use, poorer diets and
lower levels of physical activity. These higher rates are a product of social, environmental factors and individual factors,
which interact. Individual behavioural counselling is most likely to be effective for patients from disadvantaged backgrounds
if linked to community resources and if financial and access barriers are addressed.
Smoking is one of the preventable risk factors to show the greatest inequities across groups. Most disadvantaged groups
have significantly higher smoking rates. Smoking status varies by education level, employment status, SES, geographic
location and Indigenous status.252 While the proportion of people smoking across all of these groups either declined
significantly or remained relatively stable between 2007 and 2010, significant inequities remain. In 2010, 24.6% of people
aged over 14 years in the lowest SES areas smoked, compared with 12.5% in people from the highest SES areas. People
living in remote and very remote areas are about 1.7 times as likely to smoke as those living in major cities. While the
proportion of Aboriginal and Torres Strait Islander current daily smokers aged 15 years and over fell from 49% to 45%
between 2002 and 2008, Aboriginal and Torres Strait Islander peoples are still nearly twice as likely as non-Indigenous
people to be current daily smokers.253, 254 The Centre for Excellence in Indigenous Tobacco Control provides resources
and strategies at www.ceitc.org.au Smoking is also more prevalent in patients with long-term mental illness, who are more
prone to nicotine addiction.255
Overweight and obesity rates are higher in socioeconomically disadvantaged people and the gap between these and other
socioeconomic groups is widening.256 Aboriginal and Torres Strait Islander peoples and those from the Pacific Islands have
higher rates of overweight and obesity as well as a higher incidence of vascular disease.257 Aboriginal and Torres Strait
Islander communities in remote regions face significant access barriers to nutritious and affordable food.258, 259 Nutritious
food tends to cost more in rural and remote areas, and cost may also be an issue in low socioeconomic groups.260
Low income groups are less likely to be offered interventions to prevent being overweight261 (see Section 1: Introduction.)
Interventions to improve physical activity among socially disadvantaged patients need to be linked to community programs
that improve the physical environment and opportunities to exercise and to programs that remove cost barriers.262 Provider
attitudes are also important in building self-efficacy among patients from these groups.262, 263 Improvements in physical
activity for Aboriginal and Torres Strait Islander patients may be achieved by linking health advice with locally available and
appropriate community sport and recreation programs as well as social support programs (such as group activities).264
Risky alcohol use is also frequently associated with mental health issues.265, 266 Having both risk factors may not be readily
recognised and may reduce access to and receipt of treatment services.267 Alcohol has tended to produce a greater
burden of harm in more socially disadvantaged groups268, 269 partly through the more hazardous pattern of drinking270 and
partly through the associated poverty associated with lower SES.271 Recognition and treatment is also impeded by the
social stigma associated with problematic use of alcohol.271, 272
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8th edition
7.1 Smoking
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Smoking status and interest in quitting should be assessed for every patient over age 10 years.55, 237, 273275 All patients
who smoke, regardless of the amount they smoke, should be offered smoking cessation advice. This should include:
asking about their interest in quitting (B)
advising to stop smoking (A), agreeing on quit goals and offering pharmacotherapy if appropriate275, 276 (A)
offering referral to a proactive telephone callback cessation service (e.g. the Quitline 13 7848)277 (A)
following up to support maintenance and prevent relapse using self-help or pharmacotherapy278(A).
To assess nicotine dependence:
ask about the time to first cigarette and the number of cigarettes smoked a day. There is a high likelihood of nicotine
dependence if the person smokes within 30 minutes of waking and smokes more than 1015 cigarettes a day
explore whether the patient had withdrawal symptoms when they previously attempted to quit.
Table 7.1.1 Smoking: identifying risks

Who is at risk?
How often?
References
Average risk
Ask about quantity and frequency

of smoking (I,A). Offer smoking
cessation advice, set quit goals, offer
pharmacotherapy, referral and follow-up
as appropriate (II,A).
Opportunistically* (III,C)
55, 237, 274,

279282
Everyone over age 10 years
High risk (people who smoke and who have the following characteristics)
Aboriginal and Torres Strait

Islander peoples
Offer smoking cessation advice. Agree

on quit goals, offer pharmacotherapy
and culturally appropriate referral and
support (II,A).
Opportunistically, ideally at
every visit* (III,C)
280
People with mental illness
Offer smoking cessation advice and

make careful use of pharmacotherapy
given significant impact of nicotine
and nicotine withdrawal on drug
metabolism (I,A).
Opportunistically, ideally
55, 273, 279,

281, 282
Pregnant women
Offer smoking cessation advice, agree

on quit goals, offer referral to a quit
program (I,A).
At each antenatal visit (III,C)
273, 283285
People with other drug-related

dependencies
Offer smoking cessation advice and

make careful use of pharmacotherapy
given significant impact of nicotine
and nicotine withdrawal on drug
metabolism (I,A).
55, 279, 282,

286, 287
People with smoking-related

disease
Offer smoking cessation advice

highlighting specific disease-related
benefits of quitting; refer to smoking
programs (I,A).
55, 274, 282,

283
Parents of young babies and

children
Offer smoking cessation advice. If the

parent is unable to quit advise to:
55, 198, 274,

284, 288
smoke away from children

not smoke in confined spaces with
children (e.g. when driving) (I,A).
* See Effect of smoking abstinence on medications, Appendix 9, New Zealand smoking cessation guidelines 2007 at www.treatobacco.
net/en/uploads/documents/Treatment%20Guidelines/New%20Zealand%20treatment%20guidelines%20in%20English%202007.pdf
While enquiry about smoking should occur at every opportunity, be aware of patient sensitivity. Non-judgemental enquiry about
smoking is associated with greater patient satisfaction.283, 286, 289

8th edition
43
Implementation
At an individual patient level, GPs and their teams can influence smoking rates by systematically providing
opportunistic advice and offering support to all attending patients who smoke.44, 168, 259, 290, 291 GPs tend to underutilise
effective treatment strategies for example, referral to the Quitline,292294 pharmacotherapy,284, 288, 295, 296 and
motivational interviewing.284, 288, 297
There is a lack of evidence for greater effectiveness of stage-based approaches,298 and interest in quitting fluctuates over
time.299 The stages of change model provides a useful framework to help clinicians identify smokers and provide tailored
support for a smokers level of interest in quitting in a way that is time efficient and likely to be well received.300302
Pregnant women find it especially difficult to quit: pregnancy alters nicotine metabolism and heightens withdrawal
symptoms and the support from partners is an important element in quitting.240, 241 Higher smoking rates in disadvantaged
individuals reflect greater neighbourhood disadvantage, less social support, greater negative affect and lower selfefficacy.303 Removing access barriers and providing incentives to motivate patients to quit may improve quit rates.304, 305
A whole-of-practice approach that includes a supportive infrastructure has a big impact on GP effectiveness in
smoking cessation.236, 237, 244, 306, 307 The RACGP green book outlines a range of effective implementation strategies in
smoking cessation.244
7.2 Overweight
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
BMI and waist circumference should be measured every 2 years (A). BMI on its own may be misleading, especially
in older people and muscular individuals, and classifications may need to be adjusted for some ethnic groups.308
Waist circumference is a strong predictor of health problems.309, 310
Patients who are overweight or obese should be offered individual lifestyle education (A).121, 311, 312 Restrictive dieting
is not recommended for children and adolescents. A modest loss of 5% of starting body weight in adults who are
overweight is sufficient to achieve some health benefits.312315
Table 7.2.1 Obesity-related complications: identifying risks

Who is at risk?
How often?
References
Average risk
Assess BMI and waist circumference in all adults aged

over 18 years (I,A).
Every 2 years
(IV,D)
311, 313
Every 12 months
(IV,D)
264, 311
All patients
In children and adolescents use age-specific BMI

charts (see Section 3: Preventive activities in children
and young people) (III,C).
Offer education on nutrition* and physical activity (I,A).
Increased risk
Aboriginal and Torres Strait
Islander peoples and those
from Pacific Islands
Assess BMI and waist circumference in all adults over

age 18 years (I,B).
Offer individual or group-based education on nutrition
and physical activity (II,A).
313, 316
Patients with existing diabetes

or CVD, stroke, gout or liver
disease
Identified risk
Patients who are overweight
or obese
Assess weight and waist circumference (I,B).

Develop weight management
plan
(II,B).
Every 6 months
(III,C)
311
317, 318
Consider referral for self-management support or

coaching in an individual or group-based diet or
physical activity program or allied health provider (e.g.
dietitian, exercise physiologist, psychologist).
* For more information see the NHMRC Dietary guidelines for Australian adults.
For more information see the NHMRC Physical activity guidelines.
See Obesity management guidelines: the plan should include frequent contact (not necessarily in general practice), realistic
targets, and monitoring for at least 12 months.
Review impact on changes in behaviour in 2 weeks.
44

8th edition
Table 7.2.2 Overweight and obesity: assessment and preventive interventions

Assessment
Technique
References
BMI
BMI = body weight in kilograms divided by the square of height in metres. BMI of 25 or
greater conveys increased risk
311, 319
Waist
circumference
An adults waist circumference is measured halfway between the inferior margin

of the last rib and the crest of the ilium in the mid-axillary plane over bare skin. The
measurement is taken at the end of normal expiration.
311, 319
94 cm in males and 80 cm in females conveys increased risk.

102 cm in males and 88 cm in females conveys high risk.
Weight
reduction
1. Advise that weight loss can have health benefits, including reduced BP and prevention
of diabetes in high-risk patients.
2. Start a lifestyle program that includes reduced caloric intake (aiming for 600 Kcal or
2500 KJ energy deficit) and increased physical activity (increasing to 60 minutes of
moderate-intensity 5 days per week) supported by behavioural counselling.
320, 321
3. Agree on goals, including a realistic initial target of 5% weight loss. Make contact
(visits, phone, etc.) 2 weeks after commencing the program to determine adherence
and if goals are being met.
322, 323
4. If no response (<1 kg weight or 1 cm waist) after 3 months, consider alternative

approaches, including the addition of medication such as Orlistat.
324
5. After achieving initial weight loss, advise that patients may regain weight after 2
years without a maintenance program that includes support, monitoring and relapse
prevention.
325329
Bariatric surgery may be considered in patients who fail lifestyle interventions and who
have a BMI of 35+ with comorbidities, such as poorly controlled diabetes, who are
expected to improve with weight reduction.
Table 7.2.3 Obesity and risk of CVD and type 2 diabetes in Australian adults
Classification
BMI (kg/m2)
Disease risk (relative to normal measures)
Underweight
<18.5
Healthy weight
18.524.9
Overweight
25.029.9
Increased
Obesity
30.039.9
High to very high
Severe obesity
>40
Extremely high
Reproduced from National Health and Medical Research Council. Overweight and obesity in adults a guide for general
practitioners. Canberra: NHMRC, 2003311
Implementation
Strategy
Body weight is associated with the balance between levels of dietary intake and physical activity. Environmental,
cultural, genetic and lifestyle factors all contribute to overweight and obesity. Changes in the balance between energy
intake (increasing) and energy expenditure (decreasing) have been identified as major contributors to rising obesity.
There is little consensus on the relative importance of dietary intake compared with physical activity.319, 330 Regular
physical activity is protective against unhealthy weight gain and reduces CVD risk as well as CVD risk factors such as
overweight, high BP, levels of high density lipoprotein (HDL) and total blood cholesterol, and type 2 diabetes.331333
Dietary behaviour influences the risk of coronary heart disease (CHD) and stroke due to the combined effects of
individual dietary factors and total energy intake if this leads to excess weight.331
Strategies to increase screening in this group are discussed in the RACGP green book and the National guide to a
preventive health assessment in Aboriginal and Torres Strait Islander people, 2nd edition.

8th edition
45
7.3 Nutrition
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Ask adults how many portions of fruits or vegetables are eaten in a day and advise to follow the Dietary guidelines
for Australian adults.334 (B). Brief lifestyle advice should be given to reduce saturated fat and sodium and increase
fruit and vegetable portions (2 + 5 portions) as these are associated with a lower risk of CVD and diabetes.335
Breastfeeding should be promoted as the most appropriate method for feeding infants and one that offers
protection against infection and some chronic diseases.336 See Section 3: Preventive activities in children and young
people for nutrition-related recommendations.
Table 7.3.1 Nutrition-related complications: identifying risk

Who is at risk?
How often?
References
Average risk
Ask about number of portions of fruits

and vegetables eaten per day, amount of
sodium, and amount of saturated fat eaten
(II,B).
Every 2 years
(IV,D)
292, 337, 338
Every 6 months
(III,C)
338341
All patients
All patients should be advised to follow the

NHMRC Dietary guidelines for Australian
adults and the Heart Foundation guidelines
(see Table 7.3.2).
High risk
Overweight or obese
High cardiovascular absolute risk
(>15%)
A past or first-degree family history of
CVD (including stroke) before age 60
years. For personal history the age
doesnt matter.
Type 2 diabetes or high risk for diabetes
Provide lifestyle advice to reduce dietary

saturated fat, sodium and increase fruit and
vegetables. (See Section 7.2: Overweight
for dietary recommendations for overweight
and obesity) (II,B).
Provide self-help nutrition education
materials and refer to a dietitian or group
diet program (II,B).
46

8th edition
Table 7.3.2 Nutrition-related complications: preventive interventions

Intervention
Technique
References
Vitamin
supplements
Vitamin supplementation is not of established value in asymptomatic individuals*

(with the exception of folate and iodine in pregnancy). Routine screening for vitamin D
deficiency is not recommended in low-risk populations.
342
Dietary
recommendations
Enjoy a wide variety of foods each day:
334
five portions of vegetables and two portions of
fruit343, 344
three portions of cereals (including breads, rice, pasta and noodles)

one to two portions of lean meat, fish, poultry and/or alternatives
at least 2 g per day alpha-linolenic acid by including foods such as canola-based
or soybean-based oils and margarine spreads, seeds (especially linseeds),
nuts (particularly walnuts), legumes (including soybeans), eggs and green leafy
vegetables
drink plenty of water.
Take care to:
limit saturated fat and moderate total fat intake338 but consume about 500 mg
per day of combined docosahexaenoic acid and eicosapentaenoic acid through
a combination of the following:345 two or three serves (150 g serve) of oily fish per
week, fish oil capsules or liquid, food and drinks enriched with marine omega-3
polyunsaturated fatty acids346
limit salt intake347 to less than 6 g of salt a day (approximately 2300 mg of sodium a
day), which is approximately 1 teaspoons of salt
limit alcohol intake
consume only moderate amounts of sugars and foods containing added sugars.
prevent weight gain: be physically active and eat according to energy needs
care for food: prepare and store it safely
encourage and support breastfeeding.
Note: There are also dietary guidelines for children and adolescents: Dietary
guidelines for children and adolescents in Australia, incorporating the infant feeding
guidelines for health workers.86
For specific advice, especially patients with specific conditions, refer to a
dietitian.
The Heart Foundation has a number of nutrition position statements at
www.heartfoundation.org.au/information-for-professionals/food-professionals/Pages/
guides-policies-position-statement.aspx
Encourage
breastfeeding
Encourage and support exclusive breastfeeding for 46 months, then the introduction
of complementary foods and continued breastfeeding thereafter. It is recommended
that breastfeeding continue until age 12 months and thereafter as long as mutually
desired.
334
* Prevalence of nutritional deficiency is high in certain groups such as people with alcohol dependence and elderly living alone
or in institutions.
47

8th edition
Implementation
Strategy
Refer to general principles as discussed in Section 1: Introduction and Section 7: Prevention of chronic disease and
as outlined in the RACGP green book. Lifescripts provide guidance on portions and what foods to eat at www.health.
gov.au/internet/main/publishing.nsf/Content/lifescripts-clinical
It is important to consider cultural and religious beliefs in recommending dietary changes. A full range of Lifescripts
resources have been produced for use with Aboriginal and Torres Strait Islander peoples at www.healthinfonet.ecu.
edu.au/key-resources/promotion-resources?lid=16071
7.4 Early detection of problem drinking

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
All patients should be asked about the quantity and frequency of alcohol intake from age 15 years (A). Those
with at-risk patterns of alcohol consumption should be offered brief advice to reduce their intake348 (A). Provide
interventions using brief motivational interviewing targeted at high-risk use (I,B).349351
The lifetime risk of harm from drinking alcohol increases with the amount consumed. For healthy men and women,
drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease
or injury. Short-term risks stem from the risks of accidents and injuries occurring immediately after drinking.
Table 7.4.1 Alcohol-related complications: identifying risk

Who is at risk?
How often?
References
Low risk
Ask about the quantity and frequency of

alcohol intake (II,B).
Every 24 years (III,C)
44
Opportunistically (III,C)
44
352354
All patients aged 15 years

and over
Increased risk
Children and adolescents
Advise if drinking alcohol to drink two

drinks per day or less and no more than
four drinks on any one occasion (II,B).
Advise children aged under 15 years not to
drink (III,B).
Advise young people aged 1517 years to
delay drinking as long as possible (III,B).
Older people*
Young adults, who have a
higher risk of accidents and
injuries
Inform that there is an increased risk of

potential harm from drinking (III,B).
355
People with a family history of

alcohol dependence
356358
Individuals who are

participating or supervising
risky activities (e.g. driving,
boating, extreme sports,
diving, using illicit drugs)
Advise that non-drinking is the safest

option: driving (I,A), other areas (III,C).
Women who are pregnant or

planning a pregnancy

option (I,A).
Driving 359,
360
361364
Opportunistically or at
each antenatal visit (III,C)
44, 365, 366
48

8th edition
Who is at risk?
How often?
References
People with a physical

condition made worse by
alcohol:

option but weigh up pros and cons for
each individual (I,A).
44, 367
p
ancreatitis
Advise those with hypertension, or taking

antihypertensive medication, to limit
alcohol intake to no more than two (for
men) or one (for women) standard drinks
per day (II,B).
368370
371, 372
diabetes
hepatitis/chronic liver
disease
peptic ulcer

hypertension
sleep disorders
sexual dysfunction
other major organ disease
People with a mental health
problem made worse by
alcohol (e.g. anxiety and
depression)
Assess whether there are possible harmful

interactions between their medications and
alcohol (II,A).
People taking medications
* Older people who have a higher risk of falls and are more likely to be taking medication.354
Table 7.4.2 Alcohol-related complications: preventive interventions

Intervention
Technique
References
Brief intervention
Brief interventions for problem drinkers halve the mortality rate in this group.
44, 373
Brief advice in general practice has been demonstrated to have resulted in a

reduction in drinking of about six standard drinks per week for men.
238, 348, 356,

374, 375
The impact of brief advice on reduction in consumption for women is less clear.
356358, 374,
375
While there is no clear doseresponse curve for spending more time counselling
subjects who are drinking at risky levels, the minimum time to achieve some impact
is between 5 and 15 minutes.
While some have argued that screening of itself constitutes a brief intervention, the
impact of interventions of less than 5 minutes is less clear.
358, 375, 376

238
377
356, 376, 378
Implementation
Strategy
In the Australian setting, fewer than one in three females and one in six males with documented alcohol dependence
seek any form of treatment.379 The barriers to identifying and treating patients with risky or problematic drinking are
numerous380385 and include: stigma associated with diagnosis, gender (females less likely to receive treatment),
shorter consultations, self-perceived skills and scepticism about the benefit of treatment. Nevertheless, the number
needed to treat (return on effort) using brief interventions is one in eight: eight hazardous drinkers need to be treated
to produce one who will reduce drinking to low risk levels.238, 356, 358, 374, 375, 386
Implementation is improved through:
screening/routine enquiry of all patients in the target group, especially using non-confrontational tools
(e.g. computerised screening).387389 Alternatively, embed enquiry about drinking in opportunistic assessment
of lifestyle or use a structured questionnaire, for example the AUDIT-C (Appendix 3).390, 391 (Note that the risk
assessment should use the NHMRC guidelines and not other structured questionnaires, e.g. AUDIT-C.)
addressing barriers,392, 393 for example, ensuring that there is a supportive organisational practice
infrastructure387, 394, 395 and adequate training for clinicians394396 and practice nurses.381, 394, 397

8th edition
49
7.5 Physical activity

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
All adults should be advised to participate in 30 minutes of moderate activity on most, preferably all, days of the week (at
least 2.5 hours per week)398 (A) and to avoid prolonged sitting, which is a cardiovascular risk factor.399 While moderate
physical activity is recommended for health benefit, more vigorous exercise may confer additional cardiovascular
health and cancer prevention benefits if carried out for a minimum of 30 minutes three to four times a week.400 The
amount of physical activity can be accumulated over several bouts. The amount of activity for weight loss is greater. It
is recommended that at least 60 minutes of moderate-intensity physical activity (such as brisk walking) every day may
be required, in addition to reducing energy intake, in order to achieve measurable weight loss over a number of months
and prevent weight regain.401 Even without weight loss, physical activity can accrue health benefits.402
Table 7.5.1 Physical inactivity: identifying risk

Who is at risk?
How often?
References
Average risk
Question regarding current level

of activity (II,A).
Consider use of pedometer to
assess step count per day (III,C).
Every 2 years
(III,C)
403
Question regarding current level

of activity and readiness to be
more active (III,C).
Every visit (IV,D)
Those already performing moderate levels of activity

for 30 minutes daily on at least 5 days of the week.
Increased risk
Those not performing moderate levels of activity for
30 minutes daily on at least 5 days of the week.
Others at higher risk include teenage girls, office
workers, Aboriginal or Torres Strait Islander peoples,
and people from low socioeconomic backgrounds
and non-English speaking backgrounds.
Those with a chronic condition or other CVD risk
factors (see Section 8: Prevention of vascular and
metabolic disease).
Patients at high risk of CVD or diabetes (including
impaired glucose tolerance).
404
405
Provide brief advice and written

physical activity materials (III,C).
Refer to an exercise or physical
activity program: programs with
additional behaviour change
support may be more beneficial
(III,C).
Table 7.5.2 Physical inactivity: assessment and intervention

Assessment and
intervention
Determine level of
physical activity
Brief interventions
to increase levels of
physical activity
Technique
References
Moderate physical activity is associated with a moderate, noticeable increase in the

depth and rate of breathing while still being able to whistle or talk comfortably.
406
Question regarding current level of activity and readiness to be more active.
407
Consider use of pedometer to assess current number of steps per day over
1 week; 10 000 steps per day is regarded as sufficient although health benefits
also accrue at lower levels.
408
Interventions in general practice that have been shown to have short-term benefit in
changing behaviour related to physical activity include:
407
patient screening to identify current level of activity (including use of a pedometer) and 404
readiness to be more active
provision of brief advice or counselling on exercise
supporting written materials and/or written prescription for exercise (e.g. Physical
Activity Lifescript).
pedometer step target of 10 000 steps per day, or 2000 more than at baseline.
Physical activity program Structured programs of physical activity education and exercise may be delivered as
individual or group program and over several sessions. The Heart Foundation is at http://
heartmoves.heartfoundation.org.au and some local councils have information on local
physical activity programs. Exercise physiologists are listed at www.essa.org.au
50

8th edition
8. Prevention of vascular and metabolic disease

CVDs occur in 18% of the population, with 6.9% of the population estimated to have disability associated with
them.168 They account for 36% of all deaths. Most of the risk of these conditions can be attributed to smoking,
raising BP, dyslipidaemia obesity, physical inactivity and poor diet.409 The majority of these can be prevented by
changing behavioural and physiological risk factors. The behavioural risk factors include smoking, poor nutrition,
hazardous alcohol consumption and physical inactivity as outlined in Section 7: Prevention of chronic disease. In
addition to these, depression, social isolation and lack of quality social support are risk factors for CHD.410
These risk factors are common in the Australian population: 90% of adults aged over 45 years have at least one
modifiable risk factor and two-thirds have three or more risk factors for CVD.411 Absolute CVD risk combines risk
factors in a calculation of the probability that an individual will develop a cardiovascular event (myocardial infarction,
stroke) or other vascular disease within a specified timeframe (usually 5 years).
Health inequity
Aboriginal and Torres Strait Islander peoples, people living in rural and remote areas and lower socioeconomic groups all have
an increased risk of cardiovascular disease.252
Both biological and behavioural risk factors play a part (see Section 7: Prevention of chronic disease for a discussion of the
relationship between behavioural risk factors and social disadvantage). Low income and education are generally associated with
worse biological risk factors for CVD, including BP, lipid profiles, waist circumference, fasting glucose and insulin levels. This is
only partly mediated by behavioural risk factors and is more consistently observed for women.412
Diabetes is three to four times more common in Aboriginal and Torres Strait Islander peoples and about twice as common in the
most disadvantaged compared to the most socioeconomically advantaged groups.413 Higher prevalence is found in people born
in North Africa, the Middle East, South-East Asia, the Pacific Islands and Southern and Eastern Europe. Little regional variation
occurs within Australia.
The incidence of end-stage renal disease (ESRD) among Aboriginal and Torres Strait Islander peoples varies from up to 30 times
the national incidence in some remote areas to around double in some urban areas.414416 Factors that affect rates of ESRD in
the Aboriginal and Torres Strait Islander population include low birthweight, poor nutrition, infections such as scabies, smoking,
other behavioural risk factors and socioeconomic disadvantage.417419 There is also a threefold variation within urban areas
among non-Indigenous Australians, with higher ESRD incidence in more disadvantaged areas.420
The role of socioeconomic disadvantage in preventive activities for CVD is complex. Preventive care may be more commonly
offered to low socioeconomic groups, but may be less likely to be followed up421 or it may be less comprehensive or
complete422 suggesting additional targeted strategies may be needed for these groups. There is evidence that men from
socioeconomically disadvantaged backgrounds may be less likely to be offered statins.423
8.1 Assessment of absolute cardiovascular risk

Age
09
1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7079
General
population
Aboriginal and
Torres Strait
Islander peoples
Absolute cardiovascular risk assessment should be conducted at least every 2 years in all adults aged 45 years
and older who are not known to have CVDs or to be at clinically determined high risk (B).424 This calculation requires
information on the patients age, sex, smoking status, total and HDL cholesterol, systolic blood pressure (SBP) and
if the patient is known to have diabetes or left ventricular hypertrophy (LVH).
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8th edition
51
Table 8.1.1 Cardiovascular disease: identifying risk

Population group
What should be
done?
How often?
References
Adults aged 45 years and older not known to have CVD

or not clinically determined to be at high risk
Calculate absolute
cardiovascular risk*
4574 years (II,B)
Every 2 years
(IV,C)
424
75 years (Practice Point)

Aboriginal and Torres Strait Islander peoples aged
35 years and older not known to have CVD or not
clinically determined to be at high risk
Assess absolute CVD

risk (may underestimate
risk) (IV,C)
Every 2 years (IV,C)
* Calculate risk using the Heart Foundation risk charts (Appendix 5) or online at www.cvdcheck.org.au Blood lipid results within 5 years can
be used in the calculation of absolute CVD risk, but BP should be measured at the time of assessment.
On-therapy measures of BP and cholesterol may underestimate absolute risk and thus recently recorded pre-treatment measures may
be more appropriate to use if available. An electrocardiograph (ECG) is not required to determine LVH if not previously known.
Adults with any of the following do not require absolute CVD risk assessment using the Framingham Risk Equation because they are
already known to be at clinically determined high risk of CVD (IV,D):
diabetes and age >60 years

diabetes with microalbuminuria (>20 g/min or urine albumin:creatinine ratio (UACR) >2.5 mg/mmol for males,
>3.5 mg/mmol for females)
moderate or severe CKD (persistent proteinuria or estimated glomerular filtration rate
(eGFR) <45 mL/min/1.73 m2)
previous diagnosis of FH
SBP 180 mmHg or diastolic blood pressure (DBP) 110 mmHg
serum total cholesterol >7.5 mmol/L
Aboriginal or Torres Strait Islander peoples aged over 74 years (Practice Point).
Adults aged older than 74 years may have their absolute risk assessed with age entered as 74 years. This is likely to
underestimate 5-year risk but will give an estimate of minimum risk.425 Patients with a strong family history of CVD
(first-degree relatives) or obesity (BMI above 30 kg/m2 or more) may be at greater risk.310, 426, 427 Similarly patients with
depression and atrial fibrillation (AF) may be at increased risk.424
See Appendix 5 or www.cvdcheck.org.au
8.2 Blood pressure

Age
09
1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7079
80
Blood pressure (BP) should be measured in all adults from age 18 years (A) at least every 2 years. BP should be
interpreted in the context of an absolute cardiovascular risk assessment after age 45 years (35 years of age for Aboriginal
and Torres Strait Islander peoples) (B). Secondary causes of hypertension and white coat hypertension should be
considered.
52

8th edition
Table 8.2.1 Hypertension: identifying risk

Who is at risk?
How often?
References
Low absolute risk
Provide lifestyle advice and

education (I,B).
BP every 2 years
(III,C)
424, 428430
BP every 612
months (III,C)
310, 424,
426428, 431
BP every 612
weeks (III,C)
424, 429
<10% CVD risk
Offer pharmacotherapy if BP
persistently over 160/100
mmHg
Moderate risk
1015% absolute cardiovascular risk
Provide intensive lifestyle advice

(II,B).
Consider pharmacotherapy if
risk factors have not reduced
after 36 months of lifestyle
intervention.
Offer pharmacotherapy
simultaneously with lifestyle
intervention if BP persistently
over 160/100 mmHg or if family
history of premature CVD or
South Asian, Middle Eastern,
Maori, Aboriginal or Pacific
Islander descent (III,C).
High risk
>15% absolute cardiovascular risk
Clinically determined high risk:
diabetes with microalbuminuria (>20 g/min
or UACR >2.5 mg/mmol for males,
>3.5 mg/mmol for females)
moderate or severe CKD (persistent
proteinuria or eGFR <45 mL/min/1.73 m2)
previous diagnosis of FH
SBP 180 mmHg or DBP 110 mmHg
serum total cholesterol >7.5 mmol/L
Provide intensive lifestyle advice

(II,B)
Commence pharmacotherapy
(simultaneously with lipid
therapy unless contraindicated)
432, 433
Treatment goal is BP
140/90 mmHg in adults
without CVD including those
with CKD (I,BIII,D)* (130/80 in
people with diabetes or micro or
macroalbuminuria (UACR >2.5
mg/mmol in males and >3.5
mg/mmol in females))
Aboriginal and Torres Strait Islander peoples

aged over 74 years
High risk
Lifestyle risk factor counselling
Existing CVD (previous event, symptomatic CVD),

stroke or transient ischaemic attacks (TIAs) or
CKD
Pharmacotherapy to lower risk

(I,A)
* D recommendation for clinically determined high risk.
Every 6 months
(III,C)
429

8th edition
53
Table 8.2.2 Hypertension: preventive interventions

Intervention
Technique
References
Measure BP
Measure BP on at least two separate occasions with a calibrated mercury

sphygmomanometer, or automated device that is regularly calibrated against a mercury
sphygmomanometer. At the patients first BP assessment, measure BP on both arms.
Thereafter, use the arm with the higher reading. In patients who may have orthostatic
hypotension (e.g. the elderly, those with diabetes), measure BP in sitting position and repeat
after the patient has been standing for at least 2 minutes.
424, 429
If possible, use ambulatory BP monitoring or self-measurement for patients with any of

the following:
unusual variation between BP readings in the clinic
suspected white coat hypertension
hypertension that is resistant to drug treatment
suspected hypotensive episodes (e.g. in elderly or diabetic patients)
Risk calculation should be performed using clinical BP measurements (as the algorithms
are based on these). Ambulatory BP readings are considered to be better predictors of
outcomes than clinic BP measurements, and therefore should be used to monitor BP
lowering therapy.
Lifestyle
modification
Lifestyle risk factors should be managed at all risk levels.
424, 429
All people, regardless of their absolute risk level, should be given dietary advice. Those at
low to moderate absolute risk of CVD should be given dietary and other lifestyle advice.
(See Section 7: Prevention of chronic disease)
Advise to aim for healthy targets:
at least 30 minutes of moderate-intensity physical activity on most, if not all, days
smoking cessation
waist measurement <94 cm for men and <80 cm for women, BMI <25 kg/m2
dietary salt restriction 4 g/day (65 mmol/day sodium)
limit alcohol intake to 2 standard drinks per day for males and 1 standard drink per
day for females.
Medications
BP treatment should aim to lower BP towards (while balancing risks and benefits):
424
140/90 for adults without CVD (including those with CKD)

130/80 for adults with diabetes or with micro- or macro-albuminuria (UACR >2.5 mg/
mmol for males, >3.5 mg/mmol for females).
Treatment may commence with an ACE inhibitor, angiotensin II antagonist, calcium
channel blocker or a low-dose thiazide or thiazide-like diuretic. A second or third agent
from a different class may be added to treat towards targets.
8.3 Cholesterol and other lipids

Age
09
1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7079
General
population
Aboriginal and
Torres Strait
Islander peoples
Adults should have their fasting blood lipids assessed starting at age 45 years, every 5 years (A for males, C for
females). Lipid levels should be interpreted in the context of an absolute cardiovascular risk assessment after age
45 years (35 years for Aboriginal and Torres Strait Islander peoples) (B). Aboriginal and Torres Strait Islander adults
should have fasting lipid tests performed every 5 years from age 35 years (B).
80
54

8th edition
Table 8.3.1 Cholesterol and lipids: identifying risk

Who is at risk?
How often?
References
Low risk
Provide lifestyle advice (I,A).
Repeat fasting
lipids every
5 years*
424
Provide intensive lifestyle

advice (II,B).
Repeat fasting
lipids every
2 years
310, 424, 426,

427
Every 12 months
(III,C)
424
Every 12 months
(III,C)
434
Absolute CVD risk <10%

Moderate risk
Absolute CVD risk 1015%
Consider pharmacotherapy
if not reaching target after
6 months (I,A) or if family
history of premature CVD,
or Aboriginal or Torres Strait
Islander, South Asian, Middle
Eastern, Maori or Pacific
Islander descent (II,C).
High risk
Absolute cardiovascular risk >15%
Patient with the following clinically determined highrisk factors:
diabetes with microalbuminuria (>20 g/min or
UACR >2.5 mg/mmol for males, >3.5 mg/mmol for
females)
Provide intensive lifestyle

advice (II,C).
Commence cholesterol
lowering therapy
(simultaneously with
antihypertensive unless
contraindicated) (II,C-III,D).
CKD (persistent microalbuminuria or Stage 4 renal

failure eGFR <30 mL/min/1.73 m2) or Stage 3a
renal failure eGFR <45 mL/min/1.73 m2)
p
revious diagnosis of FH
S
BP 180 mmHg or DBP 110 mmHg
s erum total cholesterol >7.5 mmol/L
A
boriginal and Torres Strait Islander peoples aged
over 74 years
See Section 8.2: BP
High risk
Lifestyle risk factor counselling
Existing CVD (previous event, symptomatic CVD)
Pharmacotherapy to lower
risk (I,A)
* Lipid blood test results within 5 years can be used to calculate absolute CVD risk every 2 years. Patients with diabetes,
cardiac disease, stroke, hypertension or kidney disease should have their lipids tested every 12 months (III,C).
D recommendation for clinically determined high risk.

8th edition
55
Table 8.3.2 Cholesterol and lipids: preventive interventions

Intervention
Technique
References
Fasting blood lipids
Fasting total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides (TG).

If lipid levels are abnormal, a second confirmatory sample should be taken on a
separate occasion (as levels may vary between tests) before a definitive diagnosis is
made.
435
436, 437
Screening tests using capillary blood samples produce total cholesterol results that
are slightly lower than on venous blood. These may be used, providing they are
confirmed with full laboratory testing of venous blood for patients with elevated levels
and there is good follow-up.
In adults at low absolute risk of CVD, blood test results within 5 years may be used for
review of absolute cardiovascular risk unless there are reasons to the contrary.
Lifestyle
modification
Lifestyle risk factors should be managed at all risk levels.
424, 429
All people, regardless of their absolute risk level, should be given dietary advice
Those at low to moderate absolute risk of CVD should be given dietary and other
lifestyle advice (see Section 7: Prevention of chronic disease).
Advise to aim for healthy targets:
at least 30 minutes of moderate-intensity physical activity on most, if not all, days
smoking cessation
waist measurement <94 cm for men and <80 cm for women, BMI <25 kg/m2
dietary salt restriction 4 g/day (65 mmol/day sodium)
limit alcohol intake to 2 standard drinks per day for men and 1 standard drink per
day for women.
Pharmacotherapy
Lipid lowering therapy for primary prevention should (while balancing risks and
benefits) aim towards:
424
Total cholesterol <4.0 mmol/L

HDL-C 1.0 mmol/L
LDL-C <2.0 mmol/L
Non-HDL-C <2.5 mmol/L
TG <2.0 mmol/L
Treatment should commence with a statin. If LDL-C levels are not sufficiently reduced
on maximally tolerated dose of a statin, add one of ezetimibe, bile acid binding
resin or nicotinic acid. These agents may be used as monotherapy if statins cannot
be tolerated at all. If TG levels remain elevated, consider use of one of fenofibrate,
nicotinic acid or fish oil.
8.4 Type 2 diabetes

Age
09 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7079 80
General population
Aboriginal and Torres
Strait Islander peoples
Patients should be screened for diabetes every 3 years from age 40 years using AUSDRISK (B). Aboriginal and
Torres Strait Islander peoples should be screened from age 18 years. Those with a risk score of 12 or more should
be tested by fasting plasma glucose (C).
56

8th edition
Table 8.4.1 Type 2 diabetes: identifying risk

Who is at risk?
What should
be done?
How often?
References
Increased risk
AUSDRISK (III,B)
(Appendix 4)
Every 3 years
(III,C)
438
Fasting blood
sugar (III,B)
Every 3 years
(III,C)
439, 440
Fasting blood
sugar (III,B)
Every 12
months (III,C)
439
Age >40 years

High risk
Any one of following risk factors:
AUSDRISK score of 12 or more
all people with a history of a previous cardiovascular event
(acute myocardial infarction or stroke)
women with a history of gestational diabetes mellitus
women with polycystic ovary syndrome
patients on antipsychotic drugs
High risk
Those with impaired glucose tolerance test or impaired fasting
glucose (not limited by age)
Table 8.4.2 Tests to detect diabetes

Test
Technique
References
Fasting blood sugar
Measure plasma glucose levels on a fasting sample.
439
<5.5 mmol/L: diabetes unlikely

5.56.9 mmol/L fasting: may need to perform an oral glucose tolerance test
7.0 mmol/L or more fasting (>11.1 non-fasting): diabetes likely, repeat fasting
blood sugar to confirm on a separate day.
The test should be performed on venous blood and tested in a laboratory to
confirm a diagnosis.
Oral glucose tolerance
test
Before and 2 hours after a 75 gram oral glucose load is taken orally, the plasma
glucose is measured. If this is greater than 11.1 mmol/L, diabetes is likely. If the 2
hour plasma glucose is between 7.8 and 11.0 mmol/L, there is impaired glucose
tolerance. If it is less than 7.8 mmol/L, diabetes is unlikely.
439
Diabetes risk
Diabetes risk may be calculated using AUSDRISK. This calculates a score related
to the risk of developing diabetes over a 5-year period (Appendix 4).
441
HbA1c may be used as a diagnostic test for diabetes. HbA1c of 6.5% is the
diagnostic cut-off. However, this is not currently approved by the MBS as a test to
diagnose diabetes in Australia.
442
(AUSDRISK)
Glycated haemoglobin
(HbA1c)
443
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8th edition
Table 8.4.3 Type 2 diabetes: preventive interventions

Target group
Intervention
References
Pre-diabetes (impaired glucose

tolerance, impaired fasting glycaemia,
gestational diabetes) and those with
an elevated AUSDRISK score or
with other specific risk factors with
negative screening test
Increasing physical activity (e.g. 30 minutes brisk walking five

times a week) and/or weight loss reduces risk of developing
diabetes by 4060% in those at high risk.
444447
Give advice on healthy low fat diet (<30% kcal or kilojoules from
fat and <10% from saturated fat; high fibre, low glycaemic index
with cereals, legumes, vegetables and fruits), weight loss and
increased physical activity (see RACGP SNAP: A population
health guide to behavioural risk factors in general practice).
Refer patients to a dietitian and a physical activity program.
Provide pre-conception advice to women with a history of
gestational diabetes.
8.5 Stroke
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
GPs should be alert to symptoms of TIAs in those aged 45 years and older and assess early in order to prioritise
those needing urgent investigation and management. People at high risk should be questioned about symptoms of
TIA to determine appropriate action. Adults with AF should have their absolute cardiovascular risk assessed and be
treated accordingly. Patients with AF are at additional risk of thromboembolic disease and stroke.448
Table 8.5.1 Stroke: identifying risk

Who is at risk?
How often?
References
High absolute risk
Question about symptoms of TIA. If TIA, stratify risk

of stroke and consider anticoagulation* (I,A).
Every 12
months (IV,C)
424, 434,
449451 for
stroke/TIA
Either calculated >15% absolute

risk, clinical determined high risk or
pre-existing CVD or
Previous stroke (especially with
coexistent AF or high grade
(7099%) symptomatic carotid
stenosis)
If AF, determine cause of AF and treat according to

cardiovascular and thromboembolic risk (II,B).
Manage behavioural and physiological risk factors
actively. Treat with antihypertensive and lipidlowering medications unless contraindicated or
clinically inappropriate (II,B).
Previous TIA
Auscultation for carotid bruit
Auscultating for carotid bruits in asymptomatic

people is not recommended in the general adult
population as a screening tool for stroke risk.
Screening with duplex ultrasonography in this
population is not cost-effective (yields many false
positive results) coupled with the fact that the
overall benefit of surgery is at best small, hence
very careful selection of patients is needed to
justify surgery in those with severe (>60%) but
asymptomatic stenosis.
However, the presence of a carotid bruit has been
shown to be associated with increased risk of
myocardial infarction and cardiovascular death, so
may be a useful prognostic marker when assessing
cardiovascular risk generally.
Screen patients with known asymptomatic carotid
artery stenosis for other treatable causes of stroke
and treat these intensively.
* Anticoagulation with warfarin should be considered in patients with documented ischaemic stroke or TIAs due to AF.
452, 453
449
454
449
58

8th edition
Antiplatelet therapy should be considered for non-cardioembolic stroke or TIA.
Table 8.5.2 Tests to detect stroke risk

Test
Technique
Question
about TIA
Question patient or carer regarding symptoms of sudden onset of loss of focal neurological
function such as weakness or numbness of arms or legs, speech disturbance, double vision
or vertigo.
ABCD2 tool
References
All patients with suspected TIA should have stroke risk assessment including the ABCD2 tool:
434
Age: >60 years (1 point)

BP: >140/90 mmHg (1 point)
Clinical features: unilateral weakness (2 points), speech impairment without weakness (1
point)
Duration: >60 min (2 points), 1059 min (1 point)
Diabetes (1 point)
Important additional information also required:
Presence of AF, signs that might indicate carotid disease (e.g. anterior circulation signs) who
are candidates for carotid surgery or two or more TIAs within previous 7 days (crescendo
TIA)
For those deemed high risk (ABCD2 tool 47 and/or AF, potential carotid disease or
crescendo TIA): urgent brain and carotid imaging (urgent is considered immediately, but
certainly within 24 hours). If carotid territory symptoms, consider duplex ultrasound for
patients who are potential candidates for carotid revascularisation.
For those deemed high risk (ABCD2 tool 03 without AF, potential carotid disease or
crescendo TIA): CT brain (and carotid ultrasound where indicated) as soon as possible (i.e.
within 4872 hours)
For further information about secondary prevention after stroke or TIA, see www.strokefoundation.com.au
See also Section 15: Screening tests of unproven benefit.
8.6 Kidney disease

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Those at high risk
Patients should be screened for kidney disease if they are at high risk (B).
Table 8.6.1 Kidney disease: identifying risk

Who is at risk?
How often?
References
High risk
BP, ACR and eGFR (III,A)
Every 12 years*
419, 455462
Smoking 40 years
(IV,C)
Hypertension
Obesity
Family history of kidney disease
Diabetes
Aboriginal or Torres Strait Islander aged
>30 years
* 1 year for patients with hypertension or diabetes.
440, 463466
419, 439, 463,
465, 467
If ACR positive, arrange two

further samples for urine
ACR over 2 months (III,B)
468
469

8th edition
59
Table 8.6.2 Tests to detect kidney disease

Test
Technique
References
Albuminuria
Spot, untimed collection of urine for calculation UACR, preferably on a first morning void.
463, 465
Note: dipstick urine test is not adequate to identify microalbuminuria.

Albumin:creatinine ratio (ACR)

Normal
Females

Microalbuminuria
Macroalbuminuria
GFR
<3.5 mg/mmol

Males
<2.5 mg/mmol
3.535 mg/mmol

>35 mg/mmol
2.525 mg/mmol
>25 mg/mmol
This is currently automatically reported with every test for serum creatinine using the
abbreviated modification of diet in renal disease formula (staging is based on both GFR
level and UACR (normoalbuminuria, microalbuminuria or macroalbuminuria):
Stage 1 >90 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria
Stage 2 (mild) 6089 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria
Stage 3a (mod) 4559 mL/min/1.73 m2
Stage 3b (mod) 3044 mL/min/1.73 m2
Stage 4 (severe) 1529 mL/min/1.73 m2
Stage 5 (end-stage) <15 mL/min/1.73 m2
Refer patients with stage 4 or 5 to renal unit or nephrologist, and consider referral at stage
3 or earlier if:
persistent significant albuminuria (ACR 30 mg/mmol, approximately equivalent to
protein:creatinine ratio 50 mg/mmol, or urinary protein excretion 500 mg/24 hours,
rapidly declining eGFR (average (of at least three readings) decline >5 mL/min/1.73 m2
in 6 months)
CKD and hypertension that is hard to get to target despite at least three anti-hypertensive
agents
unexplained anaemia (<100 g/L) with eGFR <60mL/min/1.73m2
See www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/
ChronicKidneyDiseaseCKDManagementinGeneralPractice/CKDManagement.pdf
The eGFR may be unreliable in the following situations:
acute changes in renal function
dialysis patients
certain diets (e.g. vegetarian, high protein, recent ingestion of cooked meat)
extremes of body size
muscle diseases (may overestimate) or high muscle mass (may underestimate)
children <18 years
severe liver disease.
It has not been validated in all ethnic groups.
466, 468, 470
60

8th edition
9. Early detection of cancers

9.1 Skin cancer
General population screening for melanoma or non-melanoma skin cancer (NMSC) is not recommended as the
prerequisite (evidence to show this reduces death) is not available.471 Providing education that raises awareness of
early detection of skin cancer or its prevention is recommended.
Assess people opportunistically or when the patient is concerned (about skin lesions or their skin cancer risk) and
plan appropriate strategies for their level of risk. People generally should be encouraged to become familiar with
their skin, including skin not normally exposed to the sun, and be alert for new or changing skin lesions, particularly
people aged over 40 years.
9.1.1 Melanocytic skin cancer

Age
09 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7079
Advise on sun protection

and prevention
Screen increased and
high risk
Skin self-examination should be encouraged for high-risk individuals every 3 months (B).
All people, particularly children, should be advised to adopt protective measures when UV levels are 3 and above
(C). Sunscreen may prevent melanoma in adults,472 and generally minimising sun exposure may reduce the risk of
melanoma.472477
Table 9.1.1.1 Melanocytic skin cancer: identifying risk

Who is at risk?
What should be
done?
How often?
References
Average risk
Primary preventive
advice (III,B)
Opportunistically
471
Primary preventive
advice and
examination of skin
(III,B)
Opportunistically
471, 478
Preventive advice,
Examination of skin
(with or without
photography) and
advice on selfexamination (III,C)
Every 312
months (Practice
Point)
479
Light skin without past history of risk

Increased risk
(Risk 25 times normal)
Family history of melanoma in first-degree relative
Fair complexion, a tendency to burn rather than tan, the
presence of freckles, light eye colour, light or red hair colour
Age over 30 years (over 50 years most at risk)
Presence of solar lentigines
Past history of NMSC (age <40 years higher risk)
People with childhood high levels of UV exposure and
episodes of sunburn in childhood
High risk
(Risk >6 times normal)
Those with multiple atypical or dysplastic naevi and who
have a history of melanoma in themselves or in a firstdegree relative
80
61

8th edition
Table 9.1.1.2 Melanocytic skin cancer: preventive interventions

Intervention
Technique
References
Sun protection
advice
All people (especially children aged 10 years) should be advised to adopt protective
measures when UV levels are 3 and above. These measures include use of shade;
broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and
sun protection factor (SPF) 30+ sunscreens, (which need to be reapplied every 2 hours).
471, 480
Times when the UV is forecast to reach 3 and above and sun protection is
recommended are available from the Bureau of Meteorology. SunSmart applications
for smart phones or desktops provide real-time electronic alerts on recommended
sun protection times, maximum UV levels, and information on recommended
exposure for vitamin D. They are adjustable to specific geographic locations around
Australia at www.sunsmart.com.au
Skin examination
Before examining the skin, it is worth asking about any new, or changes in old
lesions. Characteristics of suspicious naevi include asymmetry, border irregularity,
variable colour (including a surrounding coloured halo) and diameter >6 mm elevation
(mnemonic ABCD). Naevi that stand out from the others (ugly duckling) are also
suspicious.
471, 484486
Nodular melanomas (with a much worse prognosis) are characteristically elevated,

firm, growing over the pastmonth (mnemonic EFG).
Excision biopsy or referral should be considered. Examination under surface
magnification (x 10) (after appropriate training) can assist in diagnosis.
Photography aids in monitoring skin lesions by detecting changes over time, and may
reduce the excision rate of benign lesions.481, 482
Full body skin examination has been shown in general and dermatology practice, with
and without dermatoscopy, to take on average 23 minutes.483
Self-examination
People should be advised on the specific changes that suggest melanoma, be

encouraged to become familiar with their skin, and be alert for new or changing skin
lesions. High-risk individuals should be encouraged to perform self-examination,
especially of naevi. Those at high risk can benefit from use of self-photography.
478, 487
Implementation
GPs over-excise pigmented lesions in people who are younger (age <40 years), or female, in whom they excise
relatively more benign lesions.482 GPs should be more suspicious of skin lesions in men aged over 50 years.482
9.1.2 NMSC (basal cell and squamous cell carcinoma)

Age
09
1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7079
Opportunistic
case finding
Prevention advice
High-risk individuals from age 40 years should be examined for NMSC opportunistically (B). Skin self-examination
should be encouraged for high-risk individuals (B). The most common preventable cause of NMSC is UV exposure.
All people, especially children, should be advised to use protective measures when UV levels are 3 or above (A).
Use of sunscreen helps prevent squamous cell skin cancer (B).488
80
62

8th edition
Table 9.1.2.1 NMSC: identifying risk

Who is at risk?
How often?
References
Average risk
Preventive advice (III,B)
Opportunistically
489
Preventive advice, education

to present if changes occur in
a skin lesion, and examination
of skin (III,B)
Opportunistically
489
Preventive advice, education

to present if changes occur
in a skin lesion, examination
of skin, and advice on selfexamination (III,B)
If initial opportunistic assessment

indicates the need. Every
12 months, or when patient
develops new skin lesion
(Practice Point)
Those with fair to lighter than olive

skin colour, under age 40 years
without any risk factors
Increased risk
Fair complexion, a tendency to burn
rather than tan, the presence of
freckles, light eye colour, light or red
hair colour
Family history of skin cancer
Age over 40 years
Male sex
Presence of multiple solar keratoses
People with high levels of UV
exposure such as outdoor workers
High risk
Fair complexion, a tendency to burn
rather than tan, the presence of
freckles, light eye colour, light or red
hair colour
490
Age over 40 years

Previous NMSC (up to 60% grow
another in 3 years)
Past exposure to arsenic
Immunosuppressed (e.g. post-renal
or heart transplant)
Table 9.1.2.2 Non-melanocytic skin cancer: preventive interventions

Intervention
Technique
References
Sun protection
advice
All people (particularly children) should be advised to adopt protective measures when
UV levels are 3 or above, especially between the hours of 10 am and 3 pm. These
measures include use of shade; broad-brimmed, bucket or legionnaire-style hats;
protective clothing; sunglasses; and SPF 30+ sunscreens (which need to be reapplied
every 2 hours).
491
Skin examination
Skin examination should be preceded by enquiry for relevant history (e.g. of lesions
of concern to patient or recent appearance or change in any lesions in the past few
months or years). Examination should identify skin lumps, ulcers or scaly patches,
particularly growing, scarred or inflamed lesions. Incision, shave or excision biopsy for
histology (or referral) should be considered. There are many suitable means to treat
NMSC; these include the use of surgery, cryotherapy, curettage and cytotoxic and
immune modulating creams. Examination under magnification can assist in diagnosis.
Full body skin examination has been shown to take on average 23 minutes in general
and dermatology practice, with and without dermatoscopy.
482, 486
Self-examination
People should be advised to be alert for skin lesion changes.
489

8th edition
63
9.2 Cervical cancer

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Pap test screening is recommended every 2 years for women who have ever had sex and have an intact cervix,
commencing from age 1820 years (or up to 2 years after first having sexual intercourse, whichever is later). These
recommendations are under review because evidence is challenging some of the following recommendations,492
and may change in the National Cervical Screening Program renewal. Currently, in 2012, this is in a consultation
process. Go to www.msac.gov.au/internet/msac/publishing.nsf/Content
Australia has the lowest mortality rate and the second lowest incidence of cervical cancer in the world. The success
of the cervical screening program is dependent upon the recruitment of women: 85% of women in Australia who
develop cervical cancer have either not had a Pap test or been inadequately screened in the past 10 years. Women
aged >50 years still represent an underscreened group. The introduction of the HPV vaccine as part of the National
Immunisation Program (NIP) 2007 may reduce the future incidence of cervical cancer, but is not a substitute for a
continuing screening program.
Table 9.2.1 Cervical cancer: identifying risk

Who is at risk?
How often?
References
Average risk
Pap test (III2,B)
Women who have ever had sex and still have

an intact cervix should undergo Pap test
screening.
493
All women who have ever

been sexually active
Routine screening with Pap tests should be

carried out every 2 years for women who have
no symptoms or history suggestive of cervical
pathology (Practice Point).
All women who have ever been sexually active
should start having Pap tests between age 18
and 20 years, or 12 years after first having
sexual intercourse, whichever is later.
Pap tests may cease at age 70 years for
women who have had two normal Pap tests
within the last 5 years. Women over age
70 years who have never had a Pap test, or
who request a Pap test, should be screened.
Women with female sex partners are also at
risk of developing cervical cancer and should
be screened as above.
HPV vaccination (B)
For maximal effect the vaccination should be

given prior to the onset of sexual activity. It has
no modifying effect on already acquired HPV
infections. It is available as part of the NIP for
girls in year 7.
47, 494
64

8th edition
Who is at risk?
How often?
References
Increased risk
Pap test (Practice Point)
It is important to ensure the patient always

receives the results of her test.
495, 496
Persistent infection with

high-risk HPV types
is necessary for the
development of cervical
cancer. Other risk factors
include:
immunosuppression
cigarette smoking
use of combined oral
contraception >5 years.
Low-grade squamous intraepithelial

lesions (LSIL)
A woman with a Pap test report of possible/
definite LSIL should have a repeat Pap test
in 12 months (Practice Point). If the repeat
test at 12 months shows LSIL (definite or
possible) the woman should be referred for
colposcopy.
A woman aged 30 years or more with a
Pap test report of LSIL, without a history of
negative smears in the preceding
23 years, should be offered either
colposcopy or a repeat Pap smear at
6 months (Practice Point).
High-grade squamous intraepithelial lesion
(HSIL)
Refer for colposcopic assessment and
targeted biopsy where indicated.
Glandular abnormality or adenocarcinoma
Refer for colposcopy by an experienced
gynaecologist or gynaecological oncologist.
If the woman is symptomatic or if she has
a clinically abnormal cervix, referral for
colposcopy is recommended.
Table 9.2.2 Tests to detect cervical cancer risk

Test
Technique
References
Pap test
A sample of the ectocervix using an extended tip spatula then the endocervix, using
a cytobrush, provides the best method of sampling and can be used in all age groups of
women. (The cytobrush is not recommended for use during pregnancy.) The cervical
broom can be used on its own in premenopausal women if it is possible to sample from
both sides of the transformation zone. In postmenopausal women the transformation zone
tends to be higher in the endocervical canal. The cervical cells should be placed onto a
glass slide and fixed with spray within 5 seconds. If the smear is reported as technically
unsatisfactory, it should not be repeated before 6 weeks. In postmenopausal women with
atrophic changes, it may be necessary to use vaginal oestrogen for 1421 days prior to the
test. See also Section 15: Screening tests of unproven benefit regarding evidence related to
bimanual vaginal examination.
497
HPV testing
As a primary screening tool:

Current national guidelines do not support the use of HPV testing as a primary
screening tool for cervical cancer.
493, 498, 499
In triage of LSIL:
The use of HPV testing in the triage of LSIL remains under investigation and is not
currently recommended by the National Cervical Cancer Screening guidelines.
493, 500502
In follow-up of HSIL:
In women treated for HSIL, cervical cytology plus HPV testing should be performed 12
months post-treatment and annually thereafter until both tests are negative on two
consecutive occasions, at which point women can return to the routine cervical
screening interval.
Liquid-based
cytology
Liquid-based cytology can be used as an additional test to the conventional smear but
not as a substitute. Its addition may be useful when repeating an unsatisfactory smear, or
added if requested by the woman.
503, 504

8th edition
65
Implementation
Strategy
Methods of encouraging women to undergo cervical screening include invitations, reminders, education, message
framing, counselling, risk-factor assessment, procedures and economic interventions. Evidence supports the use of
invitations and, to a lesser extent, educational materials. It is likely other methods are advantageous, but the evidence
is not as strong. Further research is required.505
9.3 Breast cancer

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
It is recommended that women aged 5069 years attend the BreastScreen Australia Program every 2 years for
screening mammograms (A).
Women should be aware that a recommendation for clinical breast examination is not possible because there is
insufficient evidence that this offers benefits to women of any age (C).
However, it is recommended that all women, whether or not they undergo mammographic screening, are aware of
how their breasts normally look and feel, and promptly report any new or unusual changes (such as a lump, nipple
changes, nipple discharge, change in skin colour, or pain in a breast) to their GP.506
Table 9.3.1 Breast cancer: identifying risk

Who is at risk?
What should be
done?
Average or only slightly higher* risk

(>95% of women)
Clarify risk at www.

nbocc.org.au/fraboc
No confirmed family history of breast cancer
Mammogram
Every 2 years from

age 5069 years
Breast awareness
(I,A)
Regular (Practice
Point)
One first-degree relative diagnosed with breast cancer at

age 50 years or older
One second-degree relative diagnosed with breast cancer
at any age
How often?
References
507
Two second-degree relatives on the same side of the family

diagnosed with breast cancer at age 50 years or older
Two first- or second-degree relatives diagnosed with
breast cancer, at age 50 years or older, but on different
sides (i.e. on each side) of the family
As a group, risk of breast cancer up to age 75 years is
between 1:11 and 1:8.
Moderately increased risk
(<4% of the female population)
One first-degree relative diagnosed with breast cancer
before the age of 50 (without the additional features of the
potentially high-risk group)
Two first-degree relatives, on the same side of the family,
diagnosed with breast cancer (without the additional
features of the potentially high-risk group)
Two second-degree relatives, on the same side of the
family, diagnosed with breast cancer, at least one before
age 50 years (without the additional features of the
potentially high-risk group)
As a group, the relative risk of breast cancer up to age 75
years is between 1:8 and 1:4.
507

nbocc.org.au/fraboc
Mammogram (III,C)
Breast awareness
Consider referral
to or consultation
with a family cancer
clinic for further
assessment and
management plan
At least every
2 years from age
5069 years
Annual
mammograms
from age 40 may
be recommended
if the woman has
a first-degree
relative <age 50
years diagnosed
with breast cancer
(Practice Point)
66

8th edition
Who is at risk?
What should be
done?
How often?
References
Potentially high risk

nbocc.org.au/fraboc
Individualised
surveillance
program. This may
include regular
clinical breast
examination, and
annual breast
imaging with
mammography,
MRI or ultrasound
507
(<1% of the female population)

Women who are at potentially high risk of ovarian cancer
Two first- or second-degree relatives on one side of the
family diagnosed with breast or ovarian cancer plus one
or more of the following features on the same side of the
family:
additional relative(s) with breast or ovarian cancer
breast cancer diagnosed before age 40 years
bilateral breast cancer
breast and ovarian cancer in the same woman
Ashkenazi Jewish ancestry
breast cancer in a male relative.
One first- or second-degree relative diagnosed with breast
cancer at age 45 years or younger plus another first- or
second-degree relative on the same side of the family with
sarcoma (bone/soft tissue) at age 45 years or younger
Member of a family in which the presence of a high-risk
breast cancer gene mutation has been established
Advise referral to a
cancer specialist
or family cancer
clinic for risk
assessment, possible
genetic testing and
management plan
Ongoing surveillance
strategies may
include regular clinical
breast examination,
breast imaging with
mammography,
magnetic resonance
imaging (MRI) or
ultrasound and
consideration of
ovarian cancer risk
(III,C)
(Practice Point)
See the National Breast and Ovarian Cancer Centre

guidelines at www.nbocc.org.au/fraboc for further
information.
As a group, risk of breast cancer up to age 75 years is
between 1:2 and 1:4.
* About 1.5 times the population average.
About 1.53 times the population average.
Population-based screening using mammography is the best early detection method available for reducing deaths from breast
cancer.508 Evidence of the benefit is strongest for women aged 5069 years. For all women there is a chance that mammography
will either miss breast cancer (false negative) or detect a change not caused by breast cancer (false positive). The chance of a false
negative or false positive result is higher in younger women because their breast tissue is denser, making it more difficult to detect
changes.
Women aged 4049 years are eligible for free 2-yearly screening mammograms through BreastScreen Australia, although they are
not targeted by the program. In deciding whether to attend for screening mammography, women in this age group should balance
the potential benefits and downsides for them, considering the evidence that screening mammography is less effective for women
in this age group than for older women. Generally, breasts become less dense as women get older, particularly after menopause,
which is why mammograms become more effective as women get closer to age 50 years. Mammographic screening is not
recommended for women aged <40 years because the reduced accuracy of mammography produces a high risk of false positive
and false negative results.506
Women aged 70 years are eligible for free 2-yearly screening mammograms through BreastScreen Australia, although they
are not targeted by the program because there is limited evidence available from randomised control trials about the benefits of
screening them.509 Women in this age group should balance the potential benefits and downsides of screening, considering their
general health and whether they have other diseases or conditions.506
More than 3 times the population average. Individual risk may be higher or lower if genetic test results are known.

8th edition
67
Table 9.3.2 Breast cancer: clinical breast examination and breast awareness
Other tests
Comment
References
Clinical breast
examination
Clinical trials in Russia and China showed that population-based screening using clinical
breast examination did not reduce the number of deaths from breast cancer. New RCTs
trials are underway in India and Egypt.
506
Breast
awareness
In Australia, despite our fully implemented mammographic screening program, most

breast cancers are diagnosed after the woman develops symptoms, or by her doctor.
If women are aware of the normal look and feel of their breasts, and report unusual
symptoms, breast cancer might be detected earlier.
506
In the past, regular breast self-examination (women examining their own breasts) was
promoted and taught. However, this is not supported by evidence of the size or stage of
tumours at diagnosis or in the number of deaths from breast cancer. Therefore, teaching
women breast self-examination is no longer recommended (I,B).
Implementation
Strategies
A systematic review of strategies for increasing the participation of women in community breast cancer screening
found five favourable active strategies: letter of invitation, mailed educational material, letter of invitation plus phone
call, phone call, and training activities plus direct reminders for the women.510
Physical activity during leisure time and at work is associated with a reduced risk of breast cancer,511 estimated as a
2040% reduction in both premenopausal and postmenopausal women.512
9.4 Ovarian cancer

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Not recommended as a preventive activity
Routinely screening for ovarian cancer using blood tests for cancer antigen (CA) 125, or transabdominal or
transvaginal ultrasound provides no benefit. Three large trials have been started: the United Kingdom Collaborative
Trial of Ovarian Cancer Screening will report in 2014; a European equivalent was commenced in 2005 and has not
reported yet; and the United States Prostate Lung Colorectal and Ovarian trial reported in 2011 with no benefits
from CA125 or transvaginal ultrasound screening.513
Table 9.4.1 Ovarian cancer: identifying risk

Who is at risk?
What should be
done?
How often?
References
Lower risk
No screening
514
Higher risk
No screening
515
Family history of ovarian cancer, especially first-degree

relatives and more than one relative (risk of about 3
times the population average)
Consider increased
frequency of screening
for breast and CRC
Those who have used the oral contraception, or

carried a pregnancy to term (risk of about half the
population average)
Presence of the breast cancer susceptibility gene 1

(BRCA1) or breast cancer susceptibility gene 2 (BRCA2)
516
68

8th edition
9.5 Oral cancer

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
There is insufficient evidence to recommend screening by visual inspection or by other screening methods.517, 518
Table 9.5.1 Oral cancer: identifying risk

Who is at risk?
What should be
done?
How often?
References
Average risk
Education regarding
prevention (Practice
Point)
Every 2 years
(Practice Point)
519
Increased risk
Opportunistic
examination of the
mouth and lips
(Practice Point)
Every 12 months
(Practice Point)
519, 520
Smokers aged >50 years, heavy drinkers, patients

chewing tobacco or areca/betel nut
Patients exposed to excessive amounts of sunlight
(at risk of lip cancer)
Table 9.5.2 Oral cancer: preventive care

Method
Technique
References
Education
All patients should be advised about the hazards of smoking or chewing tobacco,
excessive alcohol consumption and sunlight exposure
519
Oral examination
1. Examination of the extra oral areas neck, lips and facial areas looking for lumps
and swellings
521
2. Inspection of the oral cavity buccal mucosa, gums, tongue (lateral borders and
dorsum), floor of mouth and palate (looking for white or red patches, ulceration or
induration)
9.6 Colorectal cancer(CRC)

Age
High risk
09
1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7079
10 years prior to age of onset of affected family member
Organised screening by FOBT is recommended for the asymptomatic average risk population from age 50
years every 2 years (A) until age 75 years with repeated negative findings.522, 523 Increased risk is determined by
family history; this should include determining the number of relatives affected by CRC, side of family and age at
diagnosis. DRE is not recommended as a screening tool (D), (but is important in evaluating patients who present
with symptoms such as rectal bleeding).
A GP recommendation can positively influence participation in bowel cancer screening using FOBT.524526 Regular
FOBT can reduce CRC mortality by up to 16%.527
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69
Table 9.6.1 CRC: identifying risk

Who is at risk?
What should be
done?
How often?
References
Category 1: Average or slightly increased risk
FOBT (I,A)
Every 2 years from age 50 years

(Practice Point)
491, 522, 527,

528
Category 2: Moderately increased risk
Colonoscopy
522, 529, 530
(12% of the population)
Sigmoidoscopy plus
double-contrast
barium enema or
CT colonography
(performed by
an experienced
operator) acceptable
if colonoscopy is
contraindicated
Every 5 years from age 50 years,

or at an age 10 years younger
than the age of first diagnosis
of CRC in the family, whichever
comes first (Practice Point)
Asymptomatic people with:

no personal history of bowel cancer, colorectal
adenomas or ulcerative colitis and no confirmed
family history of CRC,
or
one first- or second-degree relative with CRC
diagnosed at age 55 years or older

one first-degree relative with CRC diagnosed
before age 55 years,
or
two first-degree or one first- and one seconddegree relative/s on the same side of the
family with CRC diagnosed at any age (without
potentially high-risk features as in Category 3)
Category 3: High risk (relative risk of ~420)
(<1% of the population)*
three or more first- or second-degree relatives
on the same side of the family diagnosed with
CRC (suspected Lynch syndrome, also known as
hereditary non-polyposis CRC or HNPCC) or other
Lynch syndrome-related cancers
or
two or more first- or second-degree relatives on
the same side of the family diagnosed with CRC,
including any of the following high-risk features:
Consider offering FOBT

(III,B)
In intervening years
Refer for genetic

screening of affected
relatives
Those at risk for:
Refer to bowel cancer

specialist to plan
appropriate surveillance
(III,B)
FAP: flexible
sigmoidoscopy
or
Colonoscopy in
attenuated FAP
multiple CRC in the one person
FAP (no APC mutation

defined): every 12 months from
age 1215 years to age 3035
years and every 3 years after
age 35 yearsII
Lynch syndrome: 12 yearly
from age 25 years or 5 years
earlier than the youngest
affected member of the
family (whichever is earliest).
Aspirin 100 mg/day is effective
prophylaxis
CRC before age 50 years

a family member who has or had Lynch
syndrome-related cancer
or
at least one first- or second-degree relative
with CRC, with a large number of adenomas
throughout the large bowel (suspected familial
adenomatous polyposis: FAP)
or
somebody in the family in whom the presence of a
high-risk mutation in the adenomatous polyposis
coli (APC) or one of the mismatch repair genes
has been identified
Members of proven FAP and Lynch syndrome
families who are shown not to carry the family
mutation are no longer at high risk and revert to
the average-risk group and still require populationbased screening.
HNPCC:
In intervening years
colonoscopy
Consider offering FOBT
(III,B)
(Practice Point)
529, 530
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8th edition
* Age of starting screening varies in high-risk groups: age 25 years for those with Lynch syndrome or 5 years earlier than the earliest
age of onset in the family.
Lynch syndrome criteria can be found at www.ncbi.nlm.nih.gov/pubmed/14970275 531
Attenuated FAP is characterised by a significant risk for colon cancer but fewer colonic polyps (average of 30), more proximally
located polyps, and diagnosis of colon cancer at a later age. Patients with 10100 adenomas have an attenuated form of FAP,
which can be due to APC mutation (dominantly inherited) or MUTYH bi-allelic mutations (recessive). In each case the CRC risk is
high.
FAP is an autosomal disorder caused by a germline mutation in the APC gene. APC mutation, as manifested by the development
of CRC, approaches 100% by the age of 50 years in untreated subjects. FAP, however, accounts for less than 1% of all CRC
cases. HNPCC, also known as Lynch syndrome, is due to an inherited mutation (abnormality) in a gene that normally repairs
the bodys DNA. Both disorders have an autosomal dominant mode of transmission within families and carry a very high risk for
cancer. As the HNPCC gene mutation is present in every cell in the body, other organs can also develop cancer. In untreated
FAP, mutation carriers have a lifetime risk for CRC close to 100%. In HNPCC, their risk for colorectal or other syndrome cancers is
7090%.522 Aspirin at 600 mg/day reduced Lynch syndrome cancer incidence by 5068% in the CAPP2 trial.532 Follow-up of the
low-dose aspirin RCTs.533, 534 suggests low-dose aspirin (100 mg/day) also reduces cancer incidence by half. A doseresponse
RCT in Lynch syndrome is open for recruitment at www.CAPP3.org
II
Bi-annual (6-monthly) or annual sigmoidoscopy for APC gene carriers of diagnosed FAP (colonoscopy in attenuated FAP).
Table 9.6.2 Test to detect CRC

Test
Technique
References
FOBT screening
Two main types of FOBT are available: guaiac and faecal immunochemical tests.
Immunochemical tests are preferred as they have greater sensitivity and higher uptake535
(A). Two or three serial stools should be tested, depending on the type and brand of test
being used. Follow the manufacturers instructions. It is essential that any positive FOBT
(including just one of the samples) is appropriately investigated by diagnostic tests (such
people being at least 12 times more likely to have CRC than those with a negative test).
With guaiac tests, even if a subject fails to follow dietary restrictions, it is dangerous to
assume that a positive result is a result of dietary non-compliance.
535, 536
Implementation
Strategy
Measures to increase screening in these groups include organised approaches such as employing recall and
reminders;536, 537 recommendations by the GP for the screening;537, 538 addressing capacity issues, including
convenience;537, 538 and minimising barriers such as cost.537539 See the RACGP green book.
The National Bowel Cancer Screening Program commenced in 2006 targeting specific age groups. GPs are critical,
not just in maximising participation, but managing participants with a positive FOBT.540, 541
Participation is underrepresented by Aboriginal and Torres Strait Islander peoples,198 who have lower survival rates
from CRC.542, 543
71

8th edition
9.7 Testicular cancer

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
There is insufficient evidence to routinely screen for testicular cancer using clinical or self-examination.544, 545 Those
performing testicular self-examination are not more likely to detect early-stage tumours or have better survival than
those who do not (C).
Table 9.7.1 Testicular cancer: identifying risk

Who is at risk?
How often?
References
High risk
Testicular examination
(Practice Point)
Opportunistically
(Practice Point)
544, 546, 547
Those with a history of cryptorchidism (relative risk

above average of 3.517), orchidopexy, testicular
atrophy, or previous testicular cancer (relative risk
2528)
9.8 Prostate cancer

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
Screening for prostate cancer is not recommended unless:

1. the man specifically asks for it; and
2. he is fully counselled on the pros and cons.
Routine screening for prostate cancer with DRE, PSA or transabdominal ultrasound is not recommended.548550
DRE has poor ability to detect prostate disease.551 Yet some cancers missed by PSA testing alone are detected by
DRE,551 which is why those recommending screening advocate DRE as well as PSA.
The recommendation is contentious. Two large RCTs552, 553 found none or marginal benefit. However, analysis of
the data from one centre contributing to one of these554 showed an increased survival from prostate cancer (but
not mortality from any cause) beyond 10 years. Two recent systematic reviews concluded that screening is not
effective.555, 556
Even if we were to conclude there was a survival benefit (from current or future trial data), this survival would need to
be balanced against the harms of cancer overdetection and treatment.
GPs need not raise this issue, but if men ask about prostate screening they need to be fully informed of the potential
benefits, risks and uncertainties of prostate cancer testing.556 When a patient chooses screening, both PSA and
DRE should be performed.
80
72

8th edition
Table 9.8.1 Prostate cancer: identifying risk

Who is at risk?
What should be
done?
How often?
References
Average risk
Respond to requests
for screening by
informing patients of
risks and benefits of
screening (I,A)
On demand
(Practice Point)
557559
Respond to requests
for screening by
informing patients of
risks and benefits of
screening (Practice
Point)
On demand
(Practice Point)
558560
The risk of developing prostate cancer increases with age

and positive family history. However, because prostate
cancer is normally slow growing, men older than age 75
years or with a life expectancy of less than 10 years are at
reduced threat of dying from a diagnosis of prostate cancer.
Men with uncomplicated lower urinary tract symptoms
(LUTS) do not appear to have an increased risk of prostate
cancer. The most common cause of LUTS is benign
prostate enlargement. Early prostate cancer often does not
have symptoms.
High risk
Men with one or more first-degree relatives diagnosed
under age 65 years
Men with a first-degree relative with familial breast cancer
(BRCA1 or BRCA2)
Table 9.8.2 Screening for prostate cancer

Not recommended
Justification
References
PSA screening
The most common adverse effect of radical prostatectomy is erectile

dysfunction, which affects most men (it is less common in younger men, those
with a lower PSA, and when nerve-sparing surgical techniques are used).
548550, 555,
561
Other complications are common as well, including urinary incontinence (which

is very common in the months after treatment, but returns to normal in 7590%
men after 2 years, depending on treatment type), and to a lesser extent, urinary
irritation and bowel symptoms. General feelings of vitality are lost in about
10% of men.
562
Both suicide and CVD increase enormously (8 and 11 times more, respectively)
in the week after men are given their diagnosis of prostate cancer.
563
Even diagnostic procedures following positive screening are harmful, with

Australian data showing that the risk of life-threatening sepsis needing intensive
care admission is not uncommon after biopsy.
Despite large trials, their meta-analysis suggests that prostate cancer screening
does not save lives.
564
555, 556
Implementation
Strategy
Patients who request testing should be informed about the risks and benefits of tests for prostate cancer, and
assisted to make their own decision.565 Written material, particularly decision aids, may be useful for this purpose:
see the RACGP green book and a free book providing a balanced presentation of facts566 at http://ses.library.usyd.
edu.au/bitstream/2123/6835/3/Let-sleeping-dogs-lie.pdf
Responding to the patients concerns and fulfilling medico-legal responsibilities are considerations in discussion with
patients.

8th edition
73
10. Psychosocial
GPs have an important role in the detection and management of mental illness, especially high-prevalence
conditions such as depression and anxiety. In the most recent Australian National Survey of Mental Health and
Wellbeing, the prevalence of any lifetime mental disorder was 45.5%, with a 12-month prevalence of 14.4% for
anxiety disorders and 6.2% for affective disorders.567 Patients, especially women, who experience underlying family
violence, may present with depression and anxiety.568
Health inequity
The national health survey identified that the proportion of people who reported having mental problems increased as
levels of socioeconomic disadvantage increased. In 200708, 16% of people living in the most disadvantaged areas
had a mental or behavioural problem, compared with 11% of people living in the least disadvantaged areas.569 The
likelihood of depression among low SES persons is almost double that of high SES persons (most marked for persistent
depression).570 Anxiety and affective disorders are more common in unemployed people and they are less likely to seek
help from their GP.571, 572 In patients with chronic disease, lower educational level and unemployment are predictive
of depression.573 Differences in the way depression is understood and presented may create barriers to accessing
effective depression care for patients from non-English speaking and culturally diverse backgrounds.574 Practices in
disadvantaged areas have a higher prevalence of depression to identify and manage in their patients.575
Being aware of this is important in the opportunistic screening for depression. Other general strategies to increase
screening in this group are outlined above and are discussed in the RACGP green book.
Suicide and attempted suicide are consistently associated with markers of SES disadvantage,576579 including low SES,
limited educational achievement and homelessness,580582 and are also more prevalent in Aboriginal and Torres Strait
Islander peoples.583 Refer to the National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait
Islander people, second edition.
Postpartum depression is more common in women from culturally and linguistically diverse backgrounds and they are
less likely to receive help for this.584
10.1 Depression
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569 7079+
While there is evidence that depression screening instruments have reasonable sensitivity and specificity, the
evidence for improved health outcomes and cost-effectiveness of screening for depression in primary care remains
unclear. There is evidence for routine screening for depression in the general adult population in the context of
staff-assisted support to the GP in providing depression care, case management and coordination (e.g. via practice
nurses) (B).585 There is insufficient evidence to recommend routine screening in adults or adolescents where this
level of feedback and management is not available (C).585 There is insufficient evidence to recommend screening in
children.586 Clinicians should maintain a high level of awareness for depressive symptoms in patients at high risk for
depression.
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8th edition
Table 10.1.1 Depression: identifying risk

Who is at risk?
How often?
References
Average risk
Be alert to possible
depression, but do not
routinely screen unless staffassisted depression care
supports are in place (C).
Opportunistically
585
The benefits of screening

have not been established,
particularly where access to
effective treatment and followup is not available.
At every encounter
586, 588
Adult population aged 18 years and older
Adolescents
Aged 1218 years, particularly with:
parental depression
comorbid mental health or chronic
medical conditions
experienced a major negative life event
Be alert for signs of depression

in this age group (B).
Consider use of HEADSS
assessment tool (see Section
3: Preventive activities in
children and young people)
Increased risk
Family history of depression
Other psychiatric disorders, including
substance misuse
Chronic medical conditions
Unemployment
Low SES
Recurrent screening may

be more useful in people
deemed to be at higher risk of
depression (B)
112, 587
Opportunistically
585
Maintain a high level of clinical

awareness of those at high risk
of depression.
Older adults with significant life events

(e.g. illness, cognitive decline, bereavement
or institutional placement)
All family members who have experienced
family violence
Experience of child abuse
Table 10.1.2 Test to detect depression

Test
Technique
References
Question
regarding
mood and
anhedonia
Asking two simple questions may be as effective as longer instruments:
589
Over the past 2 weeks, have you felt down, depressed or hopeless?
590
and
Over the past 2 weeks, have you felt little interest or pleasure in doing things?
Asking a patient if help is needed in addition to these two screening questions improves the
specificity of a GP diagnosis of depression (IV)
In adolescents, consider use of HEADSS assessment tool (see Section 3: Preventive
activities in children and young people).
In women in the perinatal period, the Edinburgh Postnatal Depression Scale (also known
as the EPDS) can be used to detect women requiring further assessment of possible
major depression (B in the postnatal period) at www.blackdoginstitute.org.au/docs/
CliniciansdownloadableEdinburgh.pdf or www.beyondblue.org.au/index.aspx?link_
id=103.885
See also Section 10.3: Identification of intimate partner violence, as depression is a common
reason for presentation in those experiencing violence.
591
112, 587
75

8th edition
10.2 Suicide
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Lack of evidence for routine screening with a screening instrument, but be alert for higher-risk individuals
and the possibility of suicide in those at higher risk
There is a lack of evidence for the routine screening of patients using a screening instrument (C). GPs should
be alert for higher-risk individuals and the possibility of suicide in those patients who are at higher risk. There is
evidence that detecting and treating depression has a role in suicide prevention.592, 593 For example, incidence of
suicide has decreased in older men and women in association with exposure to antidepressants.594, 595
Table 10.2.1 Suicide: identifying risk

Who is at risk?
What should
be done?
How often?
References
Average risk
No routine
screening for
suicide (III,C)
Evaluate risk for
suicide (III,C)
n/a
596598
When risk factors

present and with all
people aged 1424
years
52, 592, 595,

596
General population
Increased risk
Attempted suicide is a higher risk in the following.
Mental illness, especially mood disorders, alcohol and drug
abuse
Previous suicide attempts or deliberate self-harm
Male
Young people and older people
Those with a recent loss or other adverse event
Patients with a family history of attempted or completed
suicide
Widowed
Living alone or in prison
Chronic and terminal medical illness.
Table 10.2.2 Tests to detect suicide risk

Test
Technique
References
Evaluate the risk of suicide

in the presence of risk
factors
Assessment of risk involves enquiring into the extent of the persons suicidal
thinking and intent, including:
112
suicidal thinking If suicidal thinking is present, how frequent and

persistent is it?
plan If the person has a plan, how detailed and realistic is it?
lethality What method has the person chosen, and how lethal is it?
means Does the person have the means to carry out the method?
past history Has the person ever planned or attempted suicide?
suicide of family member or peer Has someone close to the person
attempted or completed suicide?
Consideration should also be given to:
risk and protective factors
mental state hopelessness, despair, psychosis, agitation, shame, anger,
guilt, impulsivity
substance use current misuse of alcohol or other drugs
strengths and supports availability, willingness and capacity of supports.
Patients with suicidal ideation should be questioned regarding preparatory
actions (e.g. obtaining a weapon, making a plan, putting affairs in order, giving
away prized possessions, preparing a suicide note).
76

8th edition
Test
Technique
References
Screening for psychological

distress with young people
The HEADSS tool has questions that can assist in assessing suicide risk, for
example:
587
Sometimes when people feel really down they feel like hurting, or even
killing themselves. Have you ever felt that way?
Have you ever deliberately harmed or injured yourself (cutting, burning or
putting yourself in unsafe situations, e.g. unsafe sex)?
Do you feel sad or down more than usual? How long have you felt that
way?
Have you lost interest in things you usually like?
On a scale of 1 to 10, with 1 being the worst you feel and 10 being really
great and positive, how would you rate your mood today?
10.3 Identification of intimate partner violence

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
Consider asking all pregnant adult and adolescent women about partner violence during antenatal care.599
There is insufficient evidence for screening the general population; however, there should be a low threshold for
asking about abuse, particularly when the GP suspects underlying psychosocial problems.599 Training GPs to
identify violence has resulted in increased identification and referral to services.600 There is some evidence for the
effectiveness of interventions in clinical practice to reduce partner violence.
Table 10.3.1 Intimate partner violence: identifying risk

Who is at risk?
What should be
done?
How often?
References
Increased risk
Ask about partner

violence
Opportunistically
599
Pregnant adult and adolescent women

Women with:
symptoms of mental ill-health
chronic unexplained physical symptoms
unexplained injuries
frequent attendance
Men who:
ask for help with anger
have marital problems
are wife mandated to change their behaviour
have alcohol or other substance abuse problems
were abused or witnessed intimate partner violence as a
child
Ask about
relationship and
any abusive
or controlling
behaviours

8th edition
77
Table 10.3.2 Tests to detect intimate partner violence

Test
Technique
References
Ask about
partner
violence
Victimised women stress the importance of a trusting patientdoctor relationship,

confidentiality, respectful and non-judgemental attitudes to achieving disclosure as well as
acceptance of non-disclosure and a supportive response. It is crucial for safety reasons
that any questions are asked privately, when the patient is alone not when another family
member, adult or child over the age of 2 years is present. It is a clinicians responsibility to ask
and support women regardless of their response. Asking about abuse may plant a seed for
later action.
601
The collaborative group believed that GPs should ask women who are symptomatic (e.g.
symptoms of mental ill-health, chronic unexplained, physical symptoms, unexplained injuries,
frequent attendance).
Questions and statements to make if you suspect domestic violence
Has your partner ever physically threatened or hurt you?
Is there a lot of tension in your relationship? How do you resolve arguments?
Sometimes partners react strongly in arguments and use physical force. Is this happening
to you?
Are you afraid of your partner?
Violence is very common in the home. I ask a lot of my patients about abuse because
nobody should have to live in fear of their partners.
599
78

8th edition
11. Oral hygiene

Age
<2
23
49
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
65
Good oral hygiene helps to prevent dental caries and gingivitis and improves oral health. There is evidence that use
of fluoride in water, or topically, reduces caries in children.602
Table 11.1 Oral hygiene: identifying risk

Who is at risk?
How often?
References
Increased risk
Examination of the mouth

(IV,C)
At least every 12 months
52
(More frequent dental checkups as determined by dentist)
491

Rural and remote populations
Migrant groups (especially refugees)
Lower socioeconomic groups with difficulty
accessing dental care
People with reduced saliva flow
(e.g. head and neck radiation therapy,
Sjgren syndrome, multiple drug therapy
including psychotropic medications)
Education regarding
prevention (I,B)
Recommendation of
professional or home
application of topical fluoride
pastes, gels or mouth rinses
(I,A)
603
Table 11.2 Oral hygiene: preventive interventions

Intervention
Technique
References
Education
Advise about the hazards of snacks and drinks that contain high levels of carbohydrate and
acid, especially between meals.
52, 491, 602
Advise against the use of baby bottles with any fluid apart from water at night.
Advise patients to brush teeth twice daily with fluoride toothpaste. A pea-sized amount of lowfluoride toothpaste should be used before age 6 years. Encourage to spit not rinse.
604, 605
Encourage home use of high-fluoride toothpastes, gels or mouth rinses for those at high risk.
Advise the use of sugar-free chewing gum for saliva stimulation.
606
Advise the use of mouthguards for contact sports.
607
Recommend regular dental check-ups.
Oral
examination
Fluoridation
Additional advice can be obtained from the findings of a national consensus workshop
conducted in 2011.
Inspect mouth for dental caries, stained, worn or broken teeth and inflamed or swollen gums.
608
Xerostomia may present as dry and reddened gums and increased caries rate particularly
on root surfaces.
Lift the lip of children for early identification of oral problems (see also Section 3: Preventive
activities in children and young people).
Water fluoridation is beneficial at reducing dental caries.
94, 95
602
Approximately 76% of Australians now drink fluoridated water. Details regarding fluoride
levels in Australian water supplies and recommended dosages of fluoride are provided at
www.nhmrc.gov.au/_files_nhmrc/publications/attachments/eh41_1.pdf
Implementation
Health inequity
Oral disease is more prevalent among low socioeconomic groups.Significant financial barriers to accessing dental
care remain in Australia. People on low incomes are more likely to delay dental visits and less likely to receive
appropriate dental care. Private dental insurance is associated with higher rates of dental care, but insurance is less
common in low income groups or those in regional or remote location. People who hold healthcare cards are less
likely to receive preventive dental care and more likely to receive extractions when visiting the dentist.609, 610

8th edition
79
12. Glaucoma
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
The glaucomas are a group of relatively common optic neuropathies, in which there is pathological loss of retinal
ganglion cells, progressive loss of sight and associated alteration in the retinal nerve fibre layer and optic nerve head.
Evidence supports screening people at higher risk for glaucoma (A). GPs have an important role in identifying
those at increased risk for glaucoma and referring them for testing. There is no consensus on the recommended
frequency of screening for at-risk groups.611, 612
Table 12.1 Glaucoma: identifying risk

Who is at risk?
How often?
References
Increased risk
Refer for ocular examination

510 years earlier than the age
of onset of glaucoma in the
affected relative (A).
No consensus on
frequency
611, 612
Family history of glaucoma (first-degree

relatives)
Caucasian and Asian patients aged
50 years
African descent aged 40 years
Higher risk
Patients aged >50 years with:
diabetes
myopia
long-term steroid use
migraine and peripheral vasospasm
Refer for examination

of the optic nerve head
(ophthalmoscopy),
measurement of intraocular
pressure (tonometry) and
assessment of visual fields
(perimetry).*
611, 612
abnormal BP
history of eye trauma
* This may be by ophthalmologist or optometrist.
Table 12.2 Glaucoma: preventive interventions

Intervention
Technique
References
Patient education
Educate patients about glaucoma and alert them to associated

risk factors, with advice to attend regular full comprehensive eye
examinations.
611, 612
Tonometry
Schiotz tonometry has poor sensitivity and specificity for early

detection of glaucoma. Tonometry alone is an inadequate screening
tool, as it overestimates the prevalence of glaucoma.
Perimetry (visual fields)
Not advisable in general practice as only automated perimetry is

sensitive for detecting loss of visual field due to glaucoma.
Assessment of eye structure

(ophthalmoscopy)
Indirect ophthalmoscopy performed with a slit lamp is the examination

of choice.
611, 612
80

8th edition
13. Urinary incontinence

Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
80
No evidence for screening general population
There is no evidence for screening in the general population. Case finding in those at higher risk (B).
Within the general population, up to 19% of children, 13% of men and 37% of women may be affected by some
form of urinary incontinence.613 While urinary incontinence is most common in women and increases with age,
bedwetting (enuresis) is common in children and 5.5% of children also report daytime wetting.614 In men, lower
urinary tract symptoms, including urinary incontinence, is associated with surgical or radiation treatment for prostate
cancer.615 Primary care professionals are in a position to take a more proactive approach to incontinence treatment
by screening for urinary symptoms in at-risk groups during routine appointments. There remains considerable
health decrement due to urinary incontinence in those not receiving help in a population readily accessible to
primary care services.616
Table 13.1 Urinary incontinence: identifying risk

Who is at risk?
How often?
Average risk
There is no evidence to support

screening (IV)
n/a
Higher risk
Case finding (IV,B)
Every 12 months
Perinatal and postnatal women
Ask about the occurrence of urinary

incontinence
Younger women who have had children

Women who are overweight
Men following treatment for prostate cancer
People with respiratory conditions, diabetes,
stroke, heart conditions, recent surgery or
neurological disorders
Frail elderly people or long-term care
residents
In residential aged care facilities,

residents are automatically
assessed
References
613

8th edition
81
Table 13.2 Urinary incontinence: preventive interventions

Intervention
Technique
References
Case finding
Ask probing questions such as Other people with (state conditions of higher risk here)
have had problems with bladder control. Have you had any problems with leaking
urine?
617
Simple patient survey assessment tools have been shown to be valid and reliable (A).
618
The three incontinence questions questionnaire (Appendix 6) is a simple, quick and noninvasive test with acceptable accuracy for classifying urge and stress incontinence and
may be appropriate for use in primary care settings (A).
Patients with urinary incontinence should be assessed to determine the diagnostic
category as well as underlying aetiology. This can usually be determined on the basis
of history, physical examination and urinary dipstick and culture if indicated. A post-void
residual may be required in the assessment of possible retention/overflow.
Assessment
There are four common types of incontinence:

Stress incontinence is the leaking of urine, which may occur during exercise,
coughing, sneezing, laughing, walking, lifting or playing sport. This is more common in
women, although it also occurs in men, especially after prostate surgery. Pregnancy,
childbirth and menopause are the main contributors.
Urge incontinence is a sudden and strong need to urinate. It is often associated with
frequency and nocturia, and is often due to having an over-active or unstable bladder,
neurological conditions, constipation, enlarged prostate or history of poor bladder
habits.
Mixed incontinence is a combination of both stress and urge incontinence and is
most common in older women.
Overflow incontinence is a result of bladder outflow obstruction or injury. Symptoms
may be confused with stress incontinence.
Because treatments differ, urge incontinence should be distinguished from stress
incontinence (A). The patients diagnostic category can be reliably determined using the
three incontinence questions questionnaire (Appendix 6).
The Continence Foundation of Australia Helpline (telephone 1800 33 00 66) is available
5 days a week and is staffed by qualified continence advisers. Referral information is
available regarding physiotherapy, nurse continence advisors and residual urine testing.
619
82

8th edition
14. Osteoporosis
Age
09
1014
1519
2024
2529
3034
3539
4044
4549
5054
5559
6064
6569
7079
Women
Men
Review of fracture risk factors for women aged over 45 years and men aged over 50 years is recommended (C).
Those with increased risk should have bone density assessed (A).
Osteoporosis is a disease characterised by low bone mass and micro-architectural deterioration of bone tissue,
leading to bone fragility and increased fracture risk.620 It is diagnosed on the presence of a fragility fracture (fracture
from the equivalent of a fall from standing height or less, or a fracture that under normal circumstances would not
be expected in a healthy young man or woman). For epidemiological and clinical purposes, osteoporosis is defined
by BMD as a T-score of 2.5. However, age, lifestyle factors, family history and some medications and diseases
all contribute to bone loss and increased risk of fragility fractures. Thus, the goal of prevention and treatment is to
reduce a persons overall fracture risk (not just bone density maintenance).
Methods to estimate absolute fracture risk for osteoporotic fractures are available at:
www.shef.ac.uk/FRAX
garvan.org.au/promotions/bone-fracture-risk/calculator/
As bone densitometry is part of these estimates, BMD should be considered as part of the overall fracture risk
assessment (D). Risk estimation is imperfect, but the calculators predictive performance is similar to absolute
cardiovascular risk calculators.621 Risk factors (e.g. falls, glucocorticoid use, etc.) not included in one or other risk
algorithm require clinical judgement to modify the risk estimate.
To date, there are no RCTs directly evaluating screening effectiveness, harms and intervals, whether screening is
performed by bone density screening by dual-energy X-ray absorptiometry (DXA) or by estimating absolute fracture
risk. The place of absolute fracture risk assessment in the prevention and management of osteoporosis requires
further clarification as its effectiveness is yet to be tested.
80

8th edition
83
Table 14.1 Osteoporosis: identifying risk

Who is at risk?
How often?
References
Average risk
Assessment for risk factors

(II,C)
Every 12 months
(Practice Point)
620, 621
Postmenopausal women (aged 45 years or older)

Men aged 50 years or older
Preventive advice (II,C)
Increased risk
Bone mineral densitometry and

management of risk factors
(II,A)
At presentation
and no more than
every 2 years.
Repeat when it is
likely to change
management (II,C)
622, 623
Age >60 years for men and >50 years for women
plus any of:
family history of fragility fracture
smoking
high alcohol intake (>24 standard drinks per
day for men, less for women)
Investigate for causes of

secondary osteoporosis
if indicated by history,
examination findings or BMD
result (Practice Point)
vitamin D deficiency <60 nmol (screening for

vitamin D not indicated just for risk assessment)
low body weight (BMI <20)
recurrent falls
low levels of physical activity
immobility (to the extent that person cannot
leave their home or cannot do any housework)
Where there is
a specific bone
mineral wasting
condition or
medication,
consider more
frequent repeat
of DXA if likely to
change treatment
(Practice Point)
Medical conditions and medications that may

cause secondary osteoporosis:
endocrine (e.g. hypogonadism, Cushing
syndrome, hyperparathyroidism,
hyperthyroidism)
inflammatory conditions (e.g. rheumatoid
arthritis)
malabsorption (e.g. coeliac)
CKD, chronic liver disease
drugs, especially corticosteroids (e.g. 7.5 mg x
3 months) used for immunosuppression
including as part of chronic anti-rejection therapy
in organ or bone marrow transplant, antiepileptic, aromatase inhibitors, anti-androgen,
excessive thyroxine, possibly selective serotonin
reuptake inhibitors (also known as SSRIs)
High risk of further fracture
Patients aged over 45 years who sustain a low
trauma fracture
Postmenopausal women, and men with a
suspected vertebral fracture (loss of height >3 cm,
kyphosis, back pain)
BMD and management of risk

factors (II,A)
Investigate for causes of
secondary osteoporosis
if indicated by history,
examination findings or BMD
result (Practice Point)
Recommend that such
individuals are initiated on
effective anti-osteoporosis
therapy unless there are
specific contraindications
DXA at presentation
and no more than
every 2 years (II,B)
Repeat only when
it is likely to change
management
(Practice Point)
Where there is
a specific bone
mineral wasting
condition or
medication,
consider more
frequent repeat of
DXA (Practice Point)
620
84

8th edition
Table 14.2 Osteoporosis: preventive interventions

Intervention
Technique
Assessment of
risk factors
Take a thorough history, paying particular attention to the risk factors above plus:
References
vertebral deformity (if within 510 years, this is equivalent risk as any other fragility
fracture)
loss of height (>3 cm) and/or thoracic kyphosis (consider lateral spine X-ray for
vertebral deformity)
premature menopause
anorexia nervosa or amenorrhea for greater than 12 months before age 45 years
Preventive
actions
Ensure adequate daily calcium intake: dietary calcium ((A) for prevention of bone loss,
(C) for fracture) 1200 mg/day. Exercise caution with supplements.*
Encourage healthy lifestyle (e.g. smoking cessation and limiting alcohol and caffeine
intake) (D).
Education and psychosocial support for risk factor modification (Practice Point)
Falls reduction strategies: for fracture risk reduction (Practice Point)
Encourage exercise: for prevention of bone loss (A) and fracture risk reduction
(Practice Point).
Advise on safe sun exposure levels as a source of vitamin D (II,C).
Discuss absolute risk of fracture (Practice Point)
Bone mineral
densitometry
(BMD)
BMD should be measured by DXA scanning performed on two sites, preferably anteroposterior spine and hip. Without bone-losing medical conditions (e.g. steroid use), it is
unlikely to change significantly in less than 2 years (II,B) and DXA should generally be
repeated only when patient is at risk of reaching treatment thresholds (average decrease
in T-score is usually approx 0.1/year if no specific bone-losing medical conditions)
(Practice Point). Rate of bone loss tends to be slower in early older age (60+) than in
later old age (80+), and slower in men than women.
624
* Controversial level II evidence of increased risk of cardiovascular events with calcium supplements in postmenopausal women, not
seen in dietary studies.625627
Population screening for vitamin D deficiency is not recommended, but targeted testing of people who are at risk of osteoporosis
and who are at high risk of vitamin D deficiency should be considered. Vitamin D supplements could be considered in deficient
individuals if increasing sun exposure is contraindicated or not feasible or if deficiency is more than mild (i.e. <25 nmol/L) and so is
less likely to be corrected by safe sun exposure628 (Practice Point).
Other tests for bone density

A number of other X-ray and ultrasound tests have been shown to predict fractures, although not as well as DXA.
Moreover, intervention trials have been based on cases identified through DXA assessment, so their results cannot
readily be applied to individuals identified by other means.620, 621
Implementation
Several Australian studies have shown an evidencepractice gap, where the majority of people with a fragility fracture
tend to have their fracture treated, but not the underlying osteoporosis.629, 630 Those with a previous fragility fracture
have a very high risk of further fracture, and have greatest benefit from specific anti-osteoporosis treatment. Fracture
risk reductions with optimal therapy are substantial and treatment according to current guidelines is recommended
unless absolutely contraindicated. Optimal treatment includes ensuring adequate calcium intake and correcting
vitamin D deficiency.
There are inequities in the use of BMD measurement with relative underutilisation in people from rural and remote
locations and men.631

8th edition
85
15. Screening tests of unproven benefit

The following are not recommended as screening tests in low-risk general practice populations. These tests may
have value as diagnostic tests or as tests to monitor disease progression.
Table 15.1 Screening tests not recommended in low-risk general practice populations
Screening test
Condition
Reason not to use
References for
further reading
Genetic profiling
Genetic
disorders
Limited evidence on the balance of benefits and harms, ethical

issues and uncertain utility
632, 633
Cardiac CT
CHD
No RCT evidence. RCTs of therapy show no effect on

coronary artery progression. May be of benefit in those at
intermediate risk of CHD
634636
Serum homocysteine
CHD
Value as a risk factor for CHD is uncertain and published RCTs

show no evidence of benefit by lowering levels
636638
Exercise ECG
CHD
Low yield and high false positive rate given low prevalence in
asymptomatic population
636, 639
High sensitivity
C-reactive protein
(CRP)
CVD
Some evidence of benefit (i.e. reduction in CRP linked with

reduction in major CVD events in one study, but not currently
recommended as a screening test for CVD)
636, 639643
Ankle:brachial index
(ABI)
Peripheral
vascular
disease
Longitudinal studies showing increased risk of clinical CVD if

low ABI, but there is variable reliability and low sensitivity of
assessment and no published RCT evidence showing benefit
of screening
640, 644, 645
MRI
Breast cancer
Ongoing surveillance strategies for women at high risk of

breast cancer may include imaging with MRI. A Medicare
rebate is available for MRI scans for asymptomatic women
under 50 years at high risk of breast cancer
506, 507, 646648
CA125/transvaginal
ultrasound
Ovarian cancer
There is no evidence to support the use of any test including

pelvic examination, CA125, or other biomarkers, ultrasound
(including transvaginal ultrasound), or combination of tests
for routine population-based screening for ovarian cancer.
649, 650
Vascular
Cancer
CA125 is limited by poor sensitivity in early-stage disease and

low specificity. The specificity of transvaginal ultrasound is
low. The low prevalence of ovarian cancer means that even
screening tests that have very high sensitivity and specificity
have a low positive predictive value for disease detection
Virtual colonoscopy/
CT colonography
CRC
Good sensitivity for lesions larger than 10 mm, but no

evidence of reduction of CRC incidence or mortality. Not
currently recommended
523, 651655
Whole body CT or
MRI
Cancer
Whole body imaging has not been shown to improve

quality of life and/or decrease mortality. It is associated with
additional radiation exposure and a high number of false
positive results. There are no RCTs of whole body imaging to
detect cancer or CVD
656661
86

8th edition
Screening test
Condition
Reason not to use
References
Chronic
obstructive
pulmonary
disease (COPD)
Assessment is unreliable and screening for COPD using

spirometry has no net benefit.
662665
Thyroid
dysfunction
Despite the relatively high incidence of subclinical hypothyroidism

in older women (up to 17%), there is a lack of convincing data
from controlled trials that early treatment reduces lipid levels,
symptoms or the risk for CVD in patients with mild thyroid
dysfunction detected by screening.
666669
Vitamin D
deficiency
High prevalence, variability in assessment and lack of

rigorous evidence of benefit of screening
670674
Asymptomatic
bacteriuria
(elderly)
Identifying and treating non-pregnant adults with

asymptomatic bacteriuria does not improve outcomes and
may increase antibiotic resistance
675
Lung disease
Spirometry
Endocrine
Thyroid function tests
Chronic disease prevention
Vitamin D
Infection
MSU culture
Table 15.2 Screening tests of indeterminate value

Screening test
Condition
Reason not to use
References
Pregnancy
Moderate prevalence and associated morbidity, but no

RCT evidence of benefit. There is debate about what is an
adequate level of vitamin D. High-risk groups for vitamin D
deficiency may benefit from screening and supplementation.
676679
Ultrasound
Abdominal
aneurysm
USPSTF recommend screening, but low yield as declining

incidence and ethical issues of screening only one subgroup
(male smokers), and cost-effectiveness not clear
680682
B-type natriuretic
peptide (BNP)
Congestive
cardiac failure
The evidence for screening for heart failure using BNP is mixed
despite its sensitivity and prognostic significance. It may be
useful in excluding the condition in suspected heart failure
683686
Chest CT
Lung cancer
Good sensitivity but poor specificity; one RCT underway in

smokers has preliminary results showing a 20% reduction
in mortality in the CT arm. Low-dose CT screening may
benefit individuals at an increased risk for lung cancer, but
uncertainty exists about the potential harms of screening
and the generalisability of results. Approximately 20% of
individuals in each round of screening had positive results
requiring some degree of follow-up, while approximately 1%
had lung cancer.
687689
Positron emission
tomography
computed tomography
(or PET CT scan)
Lung cancer
Good sensitivity and specificity, but no RCT results
688
Visual
impairment
No benefits of screening, even though impaired visual acuity

is common and effective treatments are available
165, 690
Women
Vitamin D
Vascular
Cancer
Elderly
Visual acuity

8th edition
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683. Felker GM, Hasselblad V, Hernandez AF, OConnor CM. Biomarker-guided therapy in chronic heart failure: a metaanalysis of randomized controlled trials. Am Heart J 2009;158(3):42230
684. Krum H, Jelinek MV, Stewart S, Sindone A, Atherton JJ. 2011 update to National Heart Foundation of Australia and
Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart
failure in Australia, 2006. Med J Aust 2011;194(8):4059
685. National Institute for Clinical Excellence. Chronic heart failure. National clinical guideline for diagnosis and management in
primary and secondary care. London: NICE, 2010
686. Porapakkham P, Zimmet H, Billah B, Krum H. B-type natriuretic peptide-guided heart failure therapy: a meta-analysis.
Arch Intern Med 2010;170(6):50714
687. Mulshine JL, van Klaveren RJ. Lung cancer screening: what is the benefit and what do we do about it? Lung Cancer
2011;71(3):2478
688. Baldwin DR. Imaging in lung cancer: recent advances in PET-CT and screening. Thorax 2011;66(4):2757
689. Bach PB, Mirkin JN, Oliver TK, Azzoli CG, Berry DA, Brawley OW, et al. Benefits and harms of CT screening for lung
cancer: a systematic review. JAMA 2012:307(22):2418-29
690. Chou R, Dana T, Bougatsos C. Screening older adults for impaired visual acuity: a review of the evidence for the US
Preventive Services Task Force. Ann Intern Med 2009;151(1):4458

8th edition
115
Appendix 1: Dutch Lipid Clinic Network Criteria for making

a diagnosis of Familial Hypercholesteroloemia (FH) in adults
Score
Family history
First-degree relative with known premature coronary and/or vascular disease (men <55 years, women <60
years)
or
First-degree relative with known LDL-cholesterol above the 95th percentile for age and sex
First-degree relative with tendinous xanthomata and/or arcus cornealis
or
Children aged less than 18 years with LDL-cholesterol above the 95th percentile for age and sex
Clinical history
Patient with premature coronary artery disease (ages as above)
Patient with premature cerebral or peripheral vascular disease (as above)
Physical examination
Tendinous xanthomata
Arcus cornealis prior to age 45 years
LDL-cholesterol (mmol/L)
LDL-C 8.5
LDL-C 6.58.4
LDL-C 5.06.4
LDL-C 4.04.9
DNA analysis: functional mutation in the LDLR, APOB or PCSK9 gene
STRATIFICATION
Total score
Definite FH
Probable FH
67
Possible FH
35
Unlikely FH
<3
116

8th edition
Modified UK Simon Broome criteria

1. DNA mutation
2. Tendon xanthomas in patient or first/second-degree relative
3. Family history MI <50 in second-degree or <60 in first-degree relative
4. Family history of cholesterol >7.5 in first- or second-degree relative
5. Cholesterol >7.5 (adult) or >6.7 (age <16 years)
6. LDL-C >4.9 (adult) or >4.0 (age <16 years)
Definite: (5 or 6) + 1
Probable: (5 or 6) + 2
Possible familial hypercholesteroloemia: (5 or 6) + (3 or 4)
Adapted from Watts GF, Sullivan DR, Poplawski N, van Bockxmeer F, Hamilton-Craig I, et al. Familial
Hypercholesterolaemia Australasia Network Consensus Group (Australian Atherosclerosis Society). Familial
hypercholesterolaemia: a model of care for Australasia. Atheroscler Suppl 2011;12(2):22163

8th edition
Appendix 2: Red flag early intervention referral guide
Reproduced with permission from Queensland Health. No further reproduction is allowed.
http://www.health.qld.gov.au/rch/professionals/brochures/red_flag.pdf
117
118

8th edition
Appendix 3: Audit-C (available for use in the public domain)

AUDIT-C Overview
The AUDIT-C is a three-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol
use disorders (including alcohol abuse or dependence). The AUDIT-C is a modified version of the 10-question
AUDIT instrument.
Clinical utility
The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous drinkersor have active alcohol use
disorders.
Scoring
The AUDIT-C is scored on a scale of 012.
Each AUDIT-C question has five answer choices. Points allocated are:

a = 0 points, b = 1 point, c = 2 points, d = 3 points, e = 4 points
I n men a score of 4 or more is considered positive, optimal for identifying hazardous drinking or active alcohol use
disorders.
In women a score of 3 or more is considered positive (same as above).
However, when the points are all from Questions 1 alone (questions 2 and 3 are zero), it can be assumed that the patient is
drinking below recommended limits and it is suggested that the provider review the patients alcohol intake over the past few
months to confirm accuracy.1
Generally, the higher the score, the more likely it is that the patients drinking is affecting their safety.
Psychometric properties
For identifying patients with heavy/hazardous drinking and/or active DSM alcohol abuse ordependence.
Men2
Women3
Sens: 0.95/Spec. 0.60
Sens: 0.66/Spec. 0.94
Sens: 0.86/Spec. 0.72
Sens: 0.48/Spec. 0.99
For identifying patients with active alcohol abuse or dependence:

Men2
Women3
Sens: 0.90/Spec. 0.45
Sens: 0.80/Spec. 0.87
Sens: 0.79/Spec. 0.56
Sens: 0.67/Spec. 0.94
1. B
radley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): Validation in
a female veterans affairs patient population. Arch Internal Med April 2003;163:821829
2. Frequently asked questions guide to using AUDIT-C can be found via the website: www.oqp.med.va.gov/general/uploads/FAQ%20AUDIT-C
3. B
ush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem
drinking. Arch Internal Med 1998(3):178995
www.thenationalcouncil.org/galleries/business-practice%20files/tool_auditc.pdf

8th edition
Audit-C Questionnaire
Patient name ____________________________________________________ Date of visit ______________
1. How often do you have a drink containing alcohol?
a. Never
b.
Monthly or less
c.
24 times a month
d.
23 times a week
e.
4 or more times a week
2. How many standard drinks containing alcohol do you have on a typical day?
a.
1 or 2
b.
3 or 4
c.
4 or 6
d.
7 to 9
e.
10 or more
3. How often do you have six or more drinks on one occasion?
a. Never
b.
Less than monthly
c. Monthly
d. Weekly
e.
Daily or almost daily
119
120

8th edition
Appendix 4:The Australian Type 2 Diabetes Risk

Assessment tool AUSDRISK
The Australian Type 2 Diabetes Risk Assessment Tool was originally developed by the International Diabetes Institute on behalf
of the Commonwealth, State and Territory governments as part of the COAG reducing the risk of type 2 diabetes initiative.
The Australian Type 2 Diabetes

Risk Assessment Tool
(AUSDRISK)
1. Your age group

Under 35 years
35 44 years
45 54 years
55 64 years
65 years or over
0 points
2 points
4 points
6 points
8 points
0 points
3 points
2. Your gender
Female
Male
3. Your ethnicity/country of birth:

3a. Are you of Aboriginal, Torres Strait Islander,
No
Yes
3b. Where were you born?
Australia
8. How often do you eat vegetables or fruit?

Every day
0 points
1 point
Not every day
9. On average, would you say you do at least 2.5 hours
of physical activity per week (for example, 30 minutes
a day on 5 or more days a week)?
Yes
0 points
No
2 points
10. Your waist measurement taken below the ribs
(usually at the level of the navel, and while standing)
Waist measurement (cm)
0 points
2 points
For those of Asian or Aboriginal or Torres Strait

Islander descent:
0 points
Men
Less than 90 cm
90 100 cm
More than 100 cm
Asia (including the Indian sub-continent),

Middle East, North Africa, Southern Europe
2 points
Other
0 points
4. Have either of your parents, or any of your brothers

or sisters been diagnosed with diabetes
(type 1 or type 2)?
0 points
No
Yes
3 points
5. Have you ever been found to have high blood glucose
(sugar) (for example, in a health examination,
during an illness, during pregnancy)?
No
0 points
Yes
6 points
6. Are you currently taking medication for high
blood pressure?
No
0 points
Yes
2 points
7. Do you currently smoke cigarettes or any other
tobacco products on a daily basis?
No
0 points
Yes
2 points
If you scored 6-11 points in the AUSDRISK you may be at
increased risk of type 2 diabetes. Discuss your score and your
individual risk with your doctor. Improving your lifestyle may help
reduce your risk of developing type 2 diabetes.
Women
Less than 80 cm
80 90 cm
More than 90 cm
0 points
4 points
7 points
Women
Less than 88 cm
88 100 cm
More than 100 cm
0 points
4 points
7 points
For all others:

Men
Less than 102 cm
102 110 cm
More than 110 cm
Add up your points

Your risk of developing type 2 diabetes within 5 years*:
5 or less: Low risk

Approximately one person in every 100 will develop diabetes.
6-11: Intermediate risk

For scores of 6-8, approximately one person in every 50 will
develop diabetes. For scores of 9-11, approximately one person
in every 30 will develop diabetes.
12 or more: High risk

For scores of 12-15, approximately one person in every 14 will
develop diabetes. For scores of 16-19, approximately one person
in every 7 will develop diabetes. For scores of 20 and above,
approximately one person in every 3 will develop diabetes.
*The overall score may overestimate the risk of diabetes in those aged less than 25 years.
If you scored 12 points or more in the AUSDRISK you may have

undiagnosed type 2 diabetes or be at high risk of developing the
disease. See your doctor about having a fasting blood glucose
test. Act now to prevent type 2 diabetes.
www.diabetesaustralia.com.au/PageFiles/937/AUSDRISK%20Web%2014%20July%2010.pdf
Reproduced with permission. No further reproduction is permitted.
Many Australians, particularly those over 40, are at risk of

developing type 2 diabetes through lifestyle factors such
as physical inactivity and poor nutrition. Family history of
diabetes and genetics also play a role in type 2 diabetes.
Risk factors
People with diabetes have a higher risk of developing heart

disease, stroke, high blood pressure, circulation problems,
lower limb amputations, nerve damage and damage to the
kidneys and eyes.
Type 2 diabetes is a chronic (long-term) disease marked

by high levels of sugar in the blood. It occurs when the
body does not produce enough insulin (a hormone released
by the pancreas) or respond well enough to insulin.
Type 2 diabetes is the most common form of diabetes.
There are approximately 1 million people with type 2 diabetes
currently. This figure is expected to increase significantly in
the coming years.
What is type 2 diabetes?
You can have type 2 diabetes and not know it because there
may be no obvious symptoms.
By increasing your physical activity and improving your eating

habits you can lower your risk. Eat plenty of vegetables and
high fibre cereal products every day and use a small amount
of fats and oils. Monounsaturated oils, such as olive or
canola oil, are the best choice.
If there is type 2 diabetes in your family, you should be careful

not to put on weight. Reducing your waist measurement
reduces your risk of type 2 diabetes.
You cannot change risk factors like age and your genetic
background. You can do something about being overweight,
your waist measurement, how active you are, eating habits,
or smoking.
Your lifestyle choices can prevent or, at least, delay the onset
of type 2 diabetes.
What can you do to lower your risk of

developing type 2 diabetes?
Current from: May 2010
The Australian Type 2 Diabetes Risk Assessment Tool

was developed by the Baker IDI Heart and Diabetes
Institute on behalf of the Australian, State and Territory
Governments as part of the COAG initiative to reduce
the risk of type 2 diabetes
How do you score?
The Australian Type 2 Diabetes

Risk Assessment Tool (AUSDRISK)

8th edition
6811 (1007)
121
122

8th edition
Appendix 5: Australian cardiovascular risk charts

Figure 1. Australian cardiovascular risk charts
People without diabetes

Men
Non-smoker
Women
Smoker
Non-smoker
179 *
Age
6574
160
Systolic blood pressure (mm Hg)
140
120
179 *
179 *
160
160
140
140
120
179 *
179 *
Age
5564
160
140
160
140
120
120
179 *
179 *
Age
4554
160
140
160
140
120
120
179 *
179 *
Age
3544
160
140
160
140
120
120
4
Total cholesterol:HDL ratio*
Smoker
Women
Non-smoker
People
Smoker
120
179 *
160
140
120
179 *
160
140
120
179 *
Charts in this age

bracket are for use in
Strait Islander
populations only.
160
140
120
4
* In accordance with Australian guidelines, patients with systolic blood pressure 180 mm Hg,
or a total cholesterol of > 7.5 mmol/L, should be considered at increased absolute risk of CVD.
* In accordance with Australian guidelines, pa

or a total cholesterol of > 7.5 mmol/L, shou
Risk level for 5-year cardiovascular (CVD) risk
Risk level for 5-year cardiovascular (CVD
High risk
High risk
30%
Moderate risk
1015%
2529%
Low risk
59%
30%
< 5%
2529%
2024%
2024%
1619%
1619%
How to use the risk charts

1. Identify the table relating to the persons diabetes status,
sex, smoking history and age. Smoker is defined as
either current daily cigarette smoker or former smoker
who has quit within the previous 12 months. The charts
should be used for all adults aged 4574 years (and
all Aboriginal and Torres Strait Islander adults aged
35 years and older) without known history of CVD or
already known to be at high risk.
2. Within the chart, choose the cell nearest to the
persons age, systolic blood pressure (SBP) and total
cholesterol (TC):HDL ratio. For example, the lower left
cell contains all non-smokers without diabetes who
are 3544 years and have a TC:HDL ratio of less than
4.5 and a SBP of less than 130 mm Hg.
3. The colour of the cell that the person falls into

provides their 5-year absolute cardiovascular risk
level (see legend above for risk category). For people
who fall exactly on a threshold between cells,
use the cell corresponding to higher risk. The risk
calculator may underestimate cardiovascular risk in
these groups:
Aboriginal and Torres Strait Islander adults
adults with diabetes aged 60 years or less
adults who are overweight or obese
socioeconomically deprived groups.
SBP (mean of two readings on two occasions).

Total cholesterol/high-density lipoprotein cholesterol
(HDL-C) ratio (ensure correct ratio is used).
Heart Foundation Guide to management of hypertension 2008
Reproduced with permission from the Heart Foundation. No further reproduction is permitted.
www.heartfoundation.org.au/SiteCollectionDocuments/aust-cardiovascular-risk-charts.pdf
15
Moderate risk
1015 %

8th edition
Figure 1. Australian cardiovascular risk charts (continued)
People with diabetes

Women
Non-smoker
Men
Smoker
Non-smoker
Smoker
179 *
179 *
Age
6574
140
160
140
120
120
179 *
179 *
Age
5564
160
140
160
140
120
120
179 *
179 *
Age
4554
160
140
160
140
120
120
179 *
in this age
are for use in
al and Torres
Islander
tions only.
160
179 *
Age
3544
160
140
160
140
120
120
4
* In accordance with Australian guidelines, patients with systolic blood pressure 180 mm Hg,
or a total cholesterol of > 7.5 mmol/L, should be considered at increased absolute risk of CVD.
Risk level for 5-year cardiovascular (CVD) risk

High risk
30%
2529%
Moderate risk
1015 %
Low risk
59%
< 5%
2024%
1619%
Notes: The risk charts include values for SBP alone, as this is the most
informative of conventionally measured blood pressure parameters for
cardiovascular risk.
CVD refers collectively to coronary heart disease (CHD), stroke and other vascular
disease including peripheral arterial disease and renovascular disease.
Charts are based on the NVDPAs Guidelines for the assessment of absolute
cardiovascular disease risk and adapted with permission from New Zealand
Guidelines Group. New Zealand Cardiovascular Guidelines Handbook: A Summary
Resource for Primary Care Practitioners. Second edition. Wellington, NZ: 2009.
www.nzgg.org.nz.
16
Heart Foundation Guide to management of hypertension 2008
Reproduced with permission from the Heart Foundation. No further reproduction is permitted.
Adults over the age of

60 with diabetes are
equivalent to high risk
(> 15%), regardless
of their calculated risk
level. Nevertheless,
reductions in risk
factors in this age
group can still lower
overall absolute risk.
Charts in this age

bracket are for use in
Strait Islander
populations only.
123
124

8th edition
Appendix 6: The three incontinence questions

1. During the last 3 months, have you leaked urine (even a small amount)?

Yes
No >> questionnaire completed
2. During the last 3 months, did you leak urine

(check all that apply):

a. When you were performing some physical activity, such as coughing, sneezing, lifting or exercise?
b. When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the
toilet fast enough?
c Without physical activity and without a sense of urgency?
3. During the last 3 months, did you leak urine most often:
(check only one)

a. When you are performing some physical activities such as coughing, sneezing and lifting or exercise?
b. When you had the urge or the feeling that you needed to empty your bladder but you could not get to the
toilet fast enough?
c. Without physical activity and without a sense of urgency?
d. About equally as often with physical activities as with a sense of urgency?

Response to question 3
Type of incontinence
a. Most often with physical activity
Stress only or stress predominant
b. Most often with the urge to empty the bladder
Urge only or urge predominant
c. Without physical activity or sense of urgency
Other cause only or other cause predominant
d. About equally with physical activity and sense of urgency
Mixed
Reference: Brown J, Bradley C, Subak L, Richter H, Kraus S, Brubaker L. The sensitivity and specificity of a simple test to distinguish
between urge and stress incontinence. Ann Intern Med 2006;144:71523.

8th edition
Glossary
Screening
Screening: detection of unrecognised disease or condition in the general population by using reliable
tests, examinations or other procedures that can be applied rapidly

Opportunistic screening: detection of, or case finding of specific diseases that can be controlled better
when detected early in their natural history, particularly in individuals or groups who may be predisposed
to that disease, for example, those with particular risk factors
High risk individuals: those individuals who have risk factors that are likely to predispose them to
impending disease
High index of suspicion: level of awareness of clusters of risk factors such as lifestyle, socioeconomic,
personal medical history and family medical history, which may predispose individuals to disease.
Evidence
Good evidence: there is good quality evidence obtained from randomised clinical trials to support or
reject a recommendation
Fair evidence: evidence obtained from studies such as well designed pseudo-RCTs (alternate allocation
or some other method), comparative studies with concurrent controls and allocation not randomised
(cohort studies), case control studies, or interrupted time series with a control group or comparative
studies with historical control, two or more single arm studies, or interrupted time series without a
parallel control group
Poor evidence: evidence obtained from case series, either post- or pre-test and post-test, or opinions of
respected authorities based on clinical experience, descriptive studies or reports of expert committees
No evidence: exhaustive searches have revealed there are no studies that address recommendations in
general practice for the target disease or condition.
Prevention
Primary prevention: prevention of diseases or disorders in the general population by encouraging
community-wide measures such as good nutritional status, physical fitness, immunisation and making
the environment safe. Primary prevention maintains good health and reduces the likelihood of disease
occurring
Secondary prevention: detection of the early stages of disease before symptoms occur, and the prompt
and effective intervention to prevent disease progression
Tertiary prevention: prevention or minimisation of complications or disability associated with established
disease. Preventive measures are part of the treatment or management of the target disease or
condition.
125
Healthy Profession.
Healthy Australia.

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What are the main aims of the guidelines?

What are the main aims of the guidelines?

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What types of prevention are discussed in the document?

Guidelines for preventive

activities in general practice

Guidelines for preventive

Guidelines for preventive activities in general practice

Guidelines for preventive activities in general practice

Red book taskforce members

Guidelines for preventive activities in general practice

Professor Danielle Mazza

Guidelines for preventive activities in general practice

Guidelines for preventive activities in general practice

Guidelines for preventive activities in general practice

Abbreviations and acronyms

13-valent pneumococcal conjugate vaccine

Pneumococcal polysaccharide vaccine

Asymmetry, border, colour, diameter

Angiotensin converting enzyme

dTPa Diphtheria,tetanus, acellular pertussis (adolescent/

Dual-energy X-ray absorptiometry

Elevated, firm, growing for more than 1 month

Estimated glomerular filtration rate

End stage renal disease

Familial adenomatous polyposis

Aged-related macular degeneration

Adenomatous polyposis coli

Faecal occult blood test

ASCIA The Australasian Society of Clinical Immunology

Glomerular filtration rate

AUSDRISK Australian Type 2 Diabetes Risk Assessment Tool

Human chorionic gonadotrophin

Bone mineral density

High density lipoprotein

Body mass index

High density lipoprotein-cholesterol

B-type natriuretic peptide

Breast cancer susceptibility gene 1

Breast cancer susceptibility gene 2

Haemophilus influenzae type b

Human immunodeficiency virus

Cancer antigen 125

Hereditary non-polyposis colon cancer

Coronary heart disease

Chronic kidney disease

High grade squamous intraepithelial lesion

Chronic obstructive pulmonary disease

Instrumental activities of daily living

Impaired fasting glucose

High sensitivity C-Reactive Protein

Impaired glucose tolerance test

Diastolic blood pressure

Low density lipoprotein

Low density lipoprotein-cholesterol

Dutch Lipid Clinic Network (criteria)

Low grade squamous intraepithelial lesion

Lower urinary tract symptoms

Digital rectal examination

dTPa Diphtheria,tetanus, acellular pertussis (adolescent/

ASCIA The Australasian Society of Clinical Immunology

DTpa Diphtheria,tetanus, acellular pertussis

PET-CT Positron Emission Tomography Computed