Módulo 6: Adulto (a) Adulto (a) Mayor

Objectives

Provide practical, person-centred standards for comprehensive care of adults and older adults within Guatemala’s renewed Primary Health Care Strategy, addressing priority health problems through prevention, early detection, timely treatment, referral and follow-up. Care is intended to be culturally appropriate, gender-sensitive and responsive to the differing needs of adults and older people.[1][2]

• Strengthen prevention and control of non-communicable diseases, particularly cardiovascular and metabolic diseases, chronic respiratory disease, cancer and chronic kidney disease, while recognising continuing risks from communicable diseases affecting adults.[3][1]
• Reduce behavioural and metabolic risks through healthy diets, physical activity, healthy weight, reduced salt intake, avoidance of tobacco, harmful alcohol and drugs, and appropriate prenatal care.[4][5][6]
• Prevent, identify and manage type 2 diabetes through health promotion, risk-factor assessment, screening, therapeutic control and prevention of microvascular and macrovascular complications.[7][8][9]
• Prevent hypertension and cardiovascular complications by universal blood-pressure measurement in health-service contacts, early recognition of pre-hypertension and hypertension, risk-factor modification, treatment and target-organ protection.[6][10]
• Address dyslipidaemia through lifestyle change, comprehensive cardiovascular-risk management and treatment to reduce lipid levels and prevent cardiovascular events.[11][12]
• Prevent chronic kidney disease through risk-factor control, early diagnosis, delayed progression, management of cardiovascular and uraemic complications, and renal replacement therapy for advanced disease where needed.[13][14]
• Reduce cancer risk, morbidity, disability and mortality through primary prevention, continuous screening, diagnostic confirmation, timely referral, treatment and palliative care.[15][16][17]

Implementation

Implement integrated care at the first and second levels of care, using trained providers, routine assessment, health education, clinical monitoring and referral to higher-capacity services when local resolution is not possible. The model combines individual clinical care with family, community, school, workplace, municipal and multisectoral action on health determinants and risk factors.[2][5][6]

• Assess patients through periodic and annual clinical histories, physical, nutritional and psychosocial examination, laboratory testing, counselling, vaccination review, family-planning guidance and information on available services. Record care in SIGSA, establish follow-up appointments and track referral and counter-referral.[18]
• Refer patients after stabilisation where necessary, complete referral documentation, communicate with the receiving service and follow up outcomes. Refer diabetes complications, renal disease, cardiovascular disease, suspected cancer and other cases beyond local capacity to specialist or hospital care.[2][8][19]
• Apply diabetes prevention and management across the life course through healthy lifestyles, screening of people with risk factors, glucose and lipid monitoring, self-monitoring where indicated, individualised glycaemic targets and escalation from lifestyle measures to oral medicines or insulin.[20][21][22]
• Monitor diabetes through scheduled clinical and metabolic assessments, including glucose, glycated haemoglobin, blood pressure, lipid profile, kidney function, foot examination, eye assessment, influenza vaccination and tuberculosis screening. Controlled diabetes should be reviewed at least every three months, while uncontrolled diabetes requires weekly or otherwise clinically appropriate assessment.[23][9]
• Measure blood pressure for all people attending health services, confirm hypertension through repeated measurements unless readings are markedly elevated, assess cardiovascular risks and target-organ damage, and combine lifestyle management with medicines according to clinical stage and comorbidity.[10][24][25]
• Promote kidney health through education, hydration, healthy diet and activity, avoidance of nephrotoxic medicines and harmful exposures, and screening of high-risk groups using blood pressure, serum creatinine, estimated glomerular filtration rate, urine examination and albuminuria assessment.[26][27][28]
• Manage chronic kidney disease in primary and secondary care during early stages and through specialised hospital multidisciplinary teams for stages 3 to 5 and renal replacement treatment. Repeat negative screening annually for people with diabetes, cardiovascular disease, other risk factors or age above 60, and every three years for people with hypertension or a family history of kidney disease.[29][30]
• Deliver cancer prevention through healthy-lifestyle promotion, vaccination, infection prevention, occupational and environmental carcinogen control, and age- and risk-based screening for breast, cervical, colorectal, prostate and gastric cancer.[31][15][32]
• Notify cancer cases to the National Centre for Epidemiology, confirm suspicious screening results diagnostically, and route referrals through national reference hospitals, including San Juan de Dios and Roosevelt, for regulation of onward specialised referral and follow-up.[33][19]
• Provide palliative care at first- and second-level services, including systematic cancer-pain management using the World Health Organization three-step approach and access to oral and parenteral morphine.[17]

Named public-sector actors include the Ministry of Public Health and Social Assistance, its National Epidemiology Centre and the National Statistics Institute; cancer referral also involves the national reference hospitals and specialised cancer institutions.[34][35][19]Governance structures, financing arrangements, programme budgets, workforce plans, formal performance indicators and a comprehensive accountability framework are not specified in the supplied material.[18][36][37]

Monitoring & Evaluation

Clinical monitoring is a central feature of the standards for adults and older adults, particularly for diabetes, hypertension, chronic kidney disease and cancer. Care is to be recorded in SIGSA, with follow-up appointments and tracking of referrals and counter-referrals.[18]Cancer notification to the National Centre for Epidemiology is identified as essential for reliable national cancer statistics and assessment of intervention effects.[33]

• Measure blood pressure at every consultation, assess nutritional and cardiovascular risk, and apply defined body mass index and waist-circumference thresholds.[18][38]
• Monitor diabetes through risk-based screening, regular blood glucose and glycated haemoglobin testing, annual lipid profiles, foot checks, eye assessment, renal testing, tuberculosis screening and clinical follow-up. Controlled diabetes should be reviewed at least every three months, while uncontrolled cases require weekly or otherwise clinically appropriate assessment.[21][8][39][23][9]
• Use self-monitoring of blood glucose during treatment initiation or adjustment where indicated; measure glycated haemoglobin every three months while treatment targets are being achieved and at least twice yearly once diabetes is controlled.[22]
• Apply stated diabetes targets, including fasting glucose of 70 to 115 mg/dL, two-hour post-prandial glucose of 70 to 160 mg/dL, and glycated haemoglobin below 7.0%, while individualising targets for older adults where hypoglycaemia risk is greater.[40]
• Monitor treatment safety, including renal function when estimated glomerular filtration rate is below 45 mL/min/1.73 m² and vitamin B12 deficiency or gastrointestinal effects among people receiving metformin.[41]
• Measure blood pressure monthly during antihypertensive treatment, use repeated readings across at least two visits to establish diagnosis, and monitor creatinine and serum potassium in older people receiving angiotensin-converting enzyme inhibitors.[24][42][43]
• Measure lipid profiles annually in people with diabetes or hypertension, more frequently where results are abnormal or treatment response is under review; reassess pharmacological dyslipidaemia treatment after six weeks and every six months after targets are achieved.[44][10][12][45]
• Screen people at risk of chronic kidney disease using blood pressure, serum creatinine, estimated glomerular filtration rate, urinalysis and albuminuria testing. Repeat testing annually for people with diabetes, cardiovascular disease, other risk factors or age over 60, and every three years for people with hypertension or a family history of chronic kidney disease.[28][36][29]
• Classify chronic kidney disease by estimated glomerular filtration rate, monitor progression, complications and cardiovascular risk, and refer promptly where renal function declines, proteinuria persists or complications cannot be managed locally.[46][30]
• Undertake continuous, age- and risk-based cancer screening with diagnostic confirmation of positive findings, referral follow-up and cancer-case notification. Screening schedules cover breast, cervical, colorectal, prostate and gastric cancers.[16][32][33][19]

The standards contain numerous clinical thresholds, testing schedules and referral controls, but do not establish a unified programme-level indicator framework, routine reporting schedule, evaluation methodology, audit process or named accountability body.[8][10][13][15]

Costing & Financing

Costing and financing information is largely absent. The available material does not specify budgets, allocations, financing sources, resource-mobilisation arrangements, funding gaps, costing methodologies or quantified economic assumptions for implementation of the integrated-care standards.[2][47][26][31]

• Recognise that prevention and control of chronic kidney disease risk factors is characterised as the most cost-effective approach, while late nephrology referral is associated with greater hospitalisation and treatment costs.[29][30]
• Note that lifestyle modification and metformin are cited in relation to prevention of type 2 diabetes, and metformin is described as economical, but no monetary estimate is provided.[20][21][8]
• Prioritise thiazide diuretics as effective and more affordable antihypertensive medicines, although the standards provide no price, procurement cost or budget allocation.[42]
• Recognise that meglitinides are described as having a higher cost than sulfonylureas, without a quantified value or specified currency.[41]
• Note that dyslipidaemia screening is described as cost-effective and chronic kidney disease is associated with increased health-system costs, but neither statement is accompanied by a cost-effectiveness ratio or financial estimate.[48][49]
• Provide medicines, laboratory tests, screening, referral, dialysis, transplantation, palliative care and specialist services as care components where clinically indicated, but the source supplies no associated financial values.[46][29][17]

No explicit machine-readable monetary amounts, currencies, dates, programme allocations or funding-gap estimates are available, apart from the qualitative comparative-cost entry retained below.[41]