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INTRODUCTION
Globally, a clinical approach to assessing and managing men's health is lacking. This is despite the fact that men have a shorter life expectancy and poorer health than do women. In Europe, working age men have significantly higher mortality rates than do working age women (210% higher mortality rate in the 15- to 64-year-old age range; 630,000 men per year versus 300,000 women) [1].
Health promotion, screening, and active surveillance of illnesses with timely intervention are effective in optimizing health and retarding disease progression. A more gender-specific and age-specific approach to assessing, stratifying, and improving men's health is necessary. This is particularly relevant to men who are reaching retirement age, at time at which men are at a crossroads in deciding the next phase of their lives. Their health status determines how they spend the rest of their lives.
Currently, generic tools are available that can predict mortality and morbidity, functional status, and optimal health. However, these tools have limitations. They often focus on only one domain and do not provide a more comprehensive assessment of men's overall health status. Having a strategy that incorporates these tools to prognosticate men's health will guide men in making decisions about and planning for their life. The proposed Men's Health Index (MHI) aims to provide a practical and systematic framework for assessing and stratifying older men with the intention of optimizing their health and functional status.
MATERIALS AND METHODS
The MHI was developed on the basis of literature review and expert consensus. The research team consisted of two consultant urologists, one family physician with a PhD, and two other PhD holders. The team members reviewed the literature (described below) and identified tools that are used to prognosticate men's health outcomes, including mortality, cardiovascular mortality, frailty, functional status, and fitness. The team brainstormed and developed the MHI framework through an iterative process. When there was disagreement, the researchers discussed and reached a consensus based on the aim of developing a practical framework for clinicians to use in daily practice. Several revisions were made before finalization.
We conducted a literature search by using PubMed from 1980 to 2012. We specifically looked for instruments that are used to assess men's health, frailty, and fitness and to predict life expectancy, mortality, and morbidities. Only articles in English were included. The following medical subject heading terms were used: "men's health," "frailty," "fitness," "life expectancy," and "comorbidities and "questionnaires" or "instruments." Inclusion criteria for article selection were those instruments that are easy to use in a primary care setting. The questionnaires and instruments were assessed by the researchers who then agreed on the tools to be included in the MHI. When there was disagreement, the researchers discussed and reached a consensus guided by the principle that the MHI could be used in the primary care setting targeting men aged 55 to 65 years.
This was not a systemic review but a framework of tools and questionnaires that were selected on the basis of expert consensus to assess men's health. This framework will need to be tested further and assessed in a large-scale study to devise a formula that will enable physicians to predict and advise men on their future health and survival.
RESULTS
1. Men's Health Index
The list of health assessment instruments selected are described in Table 1. Five main tools were identified: Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI), Charlson Index, Senior Fitness Test (SFT), Fitness Assessment Score (FAS), and Sitting-Rising Test (SRT). SHARE-FI is a frailty index that assesses functionality in men. The Charlson Index, on the other hand, determines the risk of death from a constellation of comorbidities or diseases. The SFT, FAS, and SRT assess the fitness status of men. The Major Men's Concerns (MMC), namely, erectile dysfunction (ED), lower urinary tract symptoms (LUTS), testosterone deficiency (TD), and smoking, are important risk factors for assessing morbidity in men. The flow chart depicted in Fig. 1 explains the stepwise approach in using these tools.
On the basis of the frailty and mortality scoring from the SHARE-FI and Charlson Index as well as the morbidity assessed by the MMC, men were stratified into different categories (frail, prefrail, or nonfrail with or without or potential for comorbidities). For each category, we proposed strategies on how to improve health and function. For men who are frail and at high risk for 10-year mortality, the health goal would be to maintain functionality and delay or retard disease complications. The current treatment should be maintained with or without secondary and tertiary prevention. For men who are prefrail, the objective is to improve health and prevent or slow down disease complications as well as to attempt to improve fitness to nonfrail status. This can be done via intensive secondary or tertiary prevention. For men who are healthy and at low risk of 10-year mortality, the objective is to optimize their life expectancy and health status via primary and secondary prevention. The SFT, SRT, and FAS can be used to classify men's health as excellent, satisfactory, or unsatisfactory.
Another component of the MHI is the mental health assessment. Men with low health risk and good function may not have a good quality of life if they have a high level of mental health burden. Similarly, a man with a high health risk and poor function may not be motivated to optimize his health if he does not have good mental health. The Depression Anxiety Stress Scale-21 (DASS21) is an example of a practical instrument to assess mental health. The scale covers three mental dimensions: anxiety, depression, and stress. Additional information about the DASS21 is available on the developer's website: http://www2.psy.unsw.edu.au/groups/dass/. Men who have mental health problems should be given appropriate counseling and psychological treatment. Therefore, men's mental health must be assessed and managed accordingly before they are advised to pursue their "post retirement" plan.
2. Pilot test
A pilot test was carried out on eight patients seen in the clinic who volunteered to take part in this study. The patients were all men in the periretirement age. The details of the patients and the results are displayed in Tables 2, 3.
Patients B, F, H were all predicted to have a 90.1% chance of survival over 10 years on the basis of the Charlson Index. They were also found to be nonfrail when assessed with the SHARE-FI score. Their fitness test results were also excellent. In these men, the aim should be to optimize health and fitness as well as to prolong quality of life. They have the option to pursue any path they wish, be it work, leisure, or any physically or mentally demanding tasks. They are fit and unlikely to jeopardize their health or life even if they cling to their highly stressful and responsible jobs or positions. Patient F, however, had a moderate score for anxiety but a normal score for stress. He may need to tone down to a less demanding job.
On the other hand, patients D and E were noted to be prefrail in their SHARE-FI score. Their predicted survival over 10 years was only 53.4%. They also fared poorly on their fitness test. Therefore, these men should aim to prevent or slow down disease progression and at the same time improve their fitness to nonfrail status through intensive treatment and secondary and tertiary prevention. Should they need to work for financial reasons, they are advised to undertake a less demanding or part-time job. This was especially so for patient E, who had mild to moderate DASS21 scores.
If patients are found to be frail with a very poor Charlson Index indicating poor survival over 10 years and in a state of poor mental health as depicted by the DASS21 scores, the aim would be for these patients to step down from any demanding and stressful jobs, undertake lifestyle changes seriously, and visit their physicians regularly to optimize secondary or tertiary prevention. The objective in these patients would be to maintain functionality and delay or slow down disease complications.
DISCUSSION
This proposed MHI is the first comprehensive tool for assessing and stratifying the health status of men by use of a systematic approach. Various health prediction tools were used as a framework to prognosticate the mortality, morbidity, and functionality of men. The aim is to assess and stratify older men with the intention of optimizing their health and functional status. The step-by-step approach is simple and can be implemented in an outpatient setting.
Although the health and life expectancies of men are steadily increasing, a significant number of men will experience various degrees of ill health or frailty when they reach 50 to 60 years of age. We believe that the SHARE-FI scale can be used to pick up about 80% of the men in this retiring age group who are not frail [2]. These nonfrail men will undergo physical fitness assessment by use of the SFT, FAS, or SRT, which will reaffirm their fitness level to be either above or below the average of men in their early 60s [3,4].
Men who have a Charlson combined comorbidity-age risk score of 1 or 2 are fit and are therefore able to pursue their "post retirement" life optimally. On the other hand, a combined Charlson score of 3 (23% mortality over 10 years) is a warning sign and men with this score should be advised to intensify their health maintenance and secondary preventive measures. A Charlson combined risk score of 4 and above predicts high mortality over 10 years. Men in this category must be advised of their high-risk status and, if necessary, review their life goals and priorities in view of their shorter life span and poorer health status [5,6].
In the MHI, we also propose using the MMC, i.e., ED, LUTS, and TD, to assess men's health status. The severity of these three major men's concerns has been shown to predict future cardiometabolic diseases. ED, LUTS, and TD are risk factors associated with metabolic syndrome [7,8], which increases the risk of cardiovascular diseases and type 2 diabetes mellitus by three to five folds [9]. The diagnosis of ED has been reported to predict coronary artery disease with a lead time of 2 to 5 years [10,11,12,13,14]. Health practitioners should not miss the opportunity to implement preventive health care and reduce the risk factors for cardiometabolic diseases in men presenting with MMC. Last, we also assess the mental health status of men, because this component is vital in determining the quality of life remaining.
We believe that the concept of assessing, stratifying, and optimizing men's health should be incorporated into routine health care, as for women's health. We believe that this holistic approach to managing men's health can be implemented by using the MHI. This index is particularly useful to primary care physicians, who are in a strategic position to engage men at the periretirement age in a conversation about their life goals on the basis of their current and predicted health status. The constellation of tests and instruments for our MHI have been pilot tested for practicality and can be completed between 30 and 60 minutes.
The MHI requires further validation, ideally in a cohort study that follows men up over a period of about 10 years. An overall index or aggregate scores of the MHI with various dimensions can then be developed for research or policy planning purposes. The proposed instruments used in the MHI may need to be modified subject to the availability of manpower and resources in clinical practice. Future men's health indexes should look into applying similar concepts to those below 50 years of age so that their health can be optimized at an early stage before disease sets in (primary prevention).
Primary prevention includes health promotion and requires action on the determinants of health to prevent disease occurring. It has been described as refocusing upstream to stop people from falling in to the waters of disease. Secondary prevention is essentially the early detection of disease, followed by appropriate intervention, such as health promotion or treatment. Tertiary prevention aims to reduce the impact of the disease and to promote quality of life through active rehabilitation [20].
The limitation of the proposed MHI is that it has not been validated and therefore should be tested for its predictive value in a cohort study. This longitudinal study has already been planned and will be launched in a confined community involving about 1,000 men between the ages of 50 and 70 years.
CONCLUSIONS
The proposed MHI is the first comprehensive tool to assess, stratify, and optimize men's health. It may be used by clinicians to manage men at retirement age and help them plan for the next phase of their life on the basis of their health status. The MHI should be further tested in the community and clinical setting to assess its validity.
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