What is the usual workup for an executive check-up?

Executive Check-Up: Evidence-Based Workup Protocol

An executive check-up should include cardiovascular risk assessment with blood pressure and lipid panel, age-appropriate cancer screening (colorectal, lung if indicated, prostate via shared decision-making), cognitive screening with validated tools like MoCA, functional assessment including gait and ADLs, basic laboratory tests (CBC, metabolic panel, HbA1c, urinalysis), and preventive care including immunizations and lifestyle counseling. 1

Cardiovascular Assessment

The cardiovascular workup forms the cornerstone of executive health screening with the highest grade of evidence:

• Measure blood pressure annually to identify hypertension, a major modifiable risk factor 1
• Obtain lipid panel (total cholesterol, LDL, HDL, triglycerides) to calculate cardiovascular risk using ACC/AHA risk calculator and guide statin therapy decisions 1
• Perform ECG as part of baseline cardiovascular evaluation 2
• One-time abdominal aortic aneurysm screening with ultrasound for men aged 65-75 who have ever smoked 1, 3
• Consider echocardiography if cardiac symptoms or abnormal physical findings are present 2

The evidence for cardiovascular screening is robust across nearly all patient populations, making this the highest-yield component of the executive exam 3.

Cancer Screening

Cancer screening should be tailored to age, risk factors, and life expectancy:

• Colorectal cancer screening should continue until at least age 75 for those with >10-year life expectancy using annual FIT, colonoscopy every 10 years, or CT colonography every 5 years 1
• Prostate cancer screening requires individualized shared decision-making discussion with PSA testing for men with ≥10-year life expectancy; digital rectal examination may be considered alongside PSA 1
• Lung cancer screening with low-dose CT for ages 55-80 with ≥30 pack-year smoking history who currently smoke or quit within past 15 years 1, 4
• Avoid over-screening in patients with significant comorbidities or limited life expectancy 1

Note that routine breast cancer and prostate cancer screening in asymptomatic adults is no longer universally recommended, emphasizing the importance of individualized risk assessment 4.

Cognitive and Mental Health Screening

Cognitive assessment is increasingly recognized as essential in executive health evaluations:

• Perform cognitive screening using MoCA (Montreal Cognitive Assessment), which takes 10-15 minutes and is sensitive for detecting mild cognitive impairment 1, 5, 6
• Alternative validated tools include Mini-Mental State Examination (MMSE, 7-10 minutes), Mini-Cog (very brief), or Short Test of Mental Status (10-15 minutes, more sensitive than MMSE for subtle deficits) 6
• Screen for depression using standardized instruments or conventional mental health interview 1
• Assess orientation to person, place, time, and situation 6
• Evaluate executive function including memory (short-term and long-term), speed of thinking and acting, and ability to shift tasks 2, 1, 6
• Document mood state, level of anxiety, presence of hopelessness, and screen for suicidal ideation 6

The MoCA is particularly valuable as it includes subtests for 5-word memory task, 6-item orientation, and letter phonemic fluency, making it well-suited for detecting executive dysfunction common in vascular cognitive impairment 2.

Functional Assessment

Functional capacity evaluation provides critical information about overall health status:

• Perform timed gait assessment to evaluate mobility and fall risk 1, 2
• Assess activities of daily living (ADLs) and instrumental activities of daily living (IADLs) including ability to manage finances, medications, transportation, household management, cooking, and shopping 1, 2
• Evaluate coordination and gait for abnormalities 6
• Check for involuntary movements or abnormalities of motor tone 6
• Measure height, weight, blood pressure, and waist circumference 2

Laboratory Testing

Basic laboratory studies should be obtained with additional tests based on clinical findings:

• Complete blood count (CBC) to assess for anemia, infection, or hematologic abnormalities 2, 1
• Comprehensive metabolic panel including serum creatinine, eGFR, electrolytes, liver function tests, and serum-corrected calcium 2
• Fasting blood glucose or HbA1c to screen for diabetes 1
• Lipid panel (covered under cardiovascular assessment) 2
• Urinalysis when clinically indicated 1
• Thyroid function tests (TSH) if symptoms suggest thyroid dysfunction 5
• Consider additional markers such as C-reactive protein, homocysteine, hemoglobin A1C, and fibrinogen for vascular risk assessment 2

The history and physical examination lead to the final diagnosis in 76% of cases, with laboratory investigation contributing to only 11% of diagnoses but significantly increasing diagnostic confidence 7.

Preventive Care and Immunizations

• Annual influenza vaccination 1
• Pneumococcal vaccination (if not previously received or due for booster) 1
• Lifestyle counseling on dietary habits, nutrition, physical activity, and social engagement 1
• Smoking cessation counseling if applicable (highest evidence for lifestyle intervention) 1, 3
• Alcohol use assessment 1

Physical Examination Components

A thorough physical examination should document:

• General appearance and nutritional status 6
• Vital signs including blood pressure, heart rate, respiratory rate 2
• Cardiovascular examination including heart sounds, peripheral pulses, and signs of heart failure 2
• Pulmonary examination for signs of respiratory disease 2
• Abdominal examination including palpation for masses or organomegaly 2
• Neurological examination including reflexes, motor strength, and sensory function 2, 6
• Skin assessment for signs of trauma, self-injury, or concerning lesions 6
• Fundoscopy if cardiovascular risk factors present 2

Special Considerations for Executives

• Bone density testing should be considered in men aged 75+ with risk factors for osteoporosis 1
• Advance care planning discussion about goals of care 1
• Assessment for sleep disorders, particularly sleep apnea, which can affect cognitive function 5
• Evaluate sensory deficits (hearing loss, vision loss) that may impact function 5
• Screen for hidden agendas, which are the reason for one-third of primary care consultations 4

Return on Investment

Executive health examinations costing approximately $400 per executive with total compensation ≥$125,000 demonstrate a net return on investment of 2.3:1, with participants experiencing lower medical claims ($5,361 vs $6,426 over 3 years) and fewer short-term disability days (2.78 vs 4.02 days over 3 years) compared to non-participants 8.

Common Pitfalls to Avoid

• Do not rely solely on cognitive test scores without considering education level, language barriers, or cultural factors when interpreting results 6
• Always obtain collateral information from reliable informants when evaluating cognitive function, as patients often lack insight into their own deficits 5, 6
• Avoid ordering extensive laboratory panels without clinical indication, as basic tests should only be performed when syncope may be due to volume loss or metabolic causes are suspected 2
• Do not overlook subtle cognitive impairment in high-functioning executives who may compensate well despite early deficits 6
• Frequency and extent of testing should be guided by overall health status and life expectancy rather than applying a one-size-fits-all approach 1