Increased familial risk for lung cancer.

For the determination of whether lung cancer clusters in families, an analysis was conducted on demographic and morbidity-mortality data, occupational and industrial experiences, and tobacco use practices for family members of 336 deceased lung cancer probands and 307 controls (probands' spouses). First-degree relatives of probands, compared with first-degree relatives of controls, showed a strong excess risk for lung cancer. Overall, male relatives of probands had a greater risk for lung cancer than did their female counterparts, and the risk was fourfold for parents of probands as compared with parents of spouses. Female relatives of probands over 40 years old were at nine times higher risk than similarly aged female controls, even among those who were non-smokers and who had not reported excessive exposure to hazardous occupations; the risk was fourfold to sixfold for heavy smokers. After control for the confounding effects of age, sex, cigarette smoking, and occupational and industrial exposures, relationship to proband remained a significant determinant of lung cancer, with a 2.4-fold greater risk among relatives of probands.

Evidence for mendelian inheritance in the pathogenesis of lung cancer.

Segregation analyses that allowed for variable age of onset of lung cancer and smoking history were performed on 337 families, each ascertained through a lung cancer proband. Results indicated compatibility of the data with mendelian codominant inheritance of a rare major autosomal gene that produces earlier age of onset of the cancer. Segregation at this putative locus could account for 69% and 47% of the cumulative incidence of lung cancer in individuals up to ages 50 and 60, respectively. The gene was involved in only 22% of all lung cancers in persons up to age 70, a reflection of an increasing proportion of noncarriers succumbing to the effects of long-term exposure to tobacco.

Dementia. Age-dependent incidence, prevalence, and mortality in the old old.

Age has been reported as a strong risk factor for dementia. Supporting data have been derived mainly from prevalence studies, which had varied criteria and sample compositions that precluded direct comparisons, especially among those aged 85 years and older. Data regarding rates of dementia are presented based on 85 incident cases in the Bronx (NY) Aging Study, a prospective study of 488 initially nondemented, old old persons (mean age on entry, 79 years). Overall, the incidence rate over 8 years of follow-up for all-cause dementia was 3.4 per 100 per year (43% Alzheimer's disease, 30% mixed Alzheimer's and vascular, and 27% other). Incidence rose significantly, irrespective of gender, as subjects were followed up through three age intervals--ages 75 to 79 years (1.3/100 per year), 80 to 84 years (3.5), and 85 years and older (6.0). The comparable age-associated prevalence rates of dementia were 3.7%, 12.2%, and 23.9%, respectively, with an overall period prevalence of 22.8%. Additionally, there was a threefold greater mortality associated with dementia. In conclusion, despite the shortened life expectancy of demented persons, dementia is a highly prevalent condition among those aged 85 years and older. Public policy attention is warranted, since this group is the fastest growing population subgroup.

Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction.

The prognostic value of pretreatment pulse pressure as a predictor of myocardial infarction and the relation of pulse pressure and in-treatment diastolic blood pressure reduction to myocardial infarction were investigated in a union-sponsored systematic hypertension control program. In a prospective study, 2207 hypertensive patients with a pretreatment systolic blood pressure greater than or equal to 160 mm Hg and/or diastolic pressure greater than or equal to 95 mm Hg grouped according to tertile of pulse pressure (PP1, < or = 46; PP2, 47 to 62; PP3, > or = 63 mm Hg) were further stratified by the degree of diastolic fall: large (L), > or = 18; moderate (M), 7 to 17; small (S), < or = 6 mm Hg. During an average follow-up of 5 years, 132 cardiovascular events (50 myocardial infarctions, 23 strokes) were observed. Myocardial infarction rates per 1000 person-years were positively related to pulse pressure (PP1, 3.5; PP2, 2.9; PP3, 7.5; PP3 versus PP1, P = .02). Wide pulse pressure was identified as a predictor of myocardial infarction (PP3 versus [PP1 + PP2]: relative risk [RR] = 2.2, 95% confidence interval [CI] = 1.2-4.1), controlling for other known risk factors by Cox regression. A curvilinear relation (resembling a J shape) between diastolic fall and myocardial infarction was observed in patients with the widest pulse pressure, PP3 (L, 9.5; M, 3.9; S, 11.2; L versus M: RR = 2.5, 95% CI = 1.0-6.2; S versus M: RR = 2.9, 95% CI = 1.1-8.0).(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of drug resistant hypertension.

Hypertension patients (1781), drawn from seven large employee groups in and around New York City, were studied to determine the prevalence of resistant hypertension among them. The blood pressure criteria for resistance (potential resistance) were failure to reach and maintain a blood pressure less than 160/95 mm Hg on two separate occasions during at least 1 year of treatment. Confirmed resistance required that during the same period of follow-up, in which at least two antihypertensive agents had been prescribed simultaneously, blood pressure control had not been achieved. Potential resistance during 1 year of treatment was found in 75 patients (4.2%), and confirmed resistance for the same period was found in 52 patients (2.9%). Diastolic resistance was far more common than systolic; the systolic/diastolic resistance was the rarest of all. Of the 52 patients with confirmed resistance for the first year, 33 achieved control in subsequent years. In sum, true resistance as defined by rigorous criteria pertaining to the hypotensive effects of pharmacological intervention in the general population is exceedingly rare.

Impact of race on treatment response and cardiovascular disease among hypertensives.

To determine the effect of race on cardiovascular disease occurrence among treated hypertensive patients, the experience of 1,807 black and 2,962 white hypertensive patients who entered a union/management--sponsored, worksite-based treatment program (1973-1985), was evaluated. Participants had similar socioeconomic profiles, equal access to health benefits, and received standard treatment. Median duration of observation was 42 months. Blacks had 48, and whites 129, of the 177 morbid (strokes and heart attacks) or mortal cardiovascular disease outcomes. At baseline, blacks had more electrocardiographic abnormalities (32% vs. 19%, p less than 0.0001), lower mean cholesterol (218 vs. 230 mg%, p less than 0.001), smoked more (35% vs. 30%, p less than 0.001), and were less likely to be treated for hypertension before entering the program (53% vs. 58%, p less than 0.01) than whites. They were also more likely than whites to belong to unions employing less skilled workers (p less than 0.0001). Overall, all-cause mortality rates between the races were similar. However, total cardiovascular disease morbidity and mortality rates were 10.5 (whites) and 6.4 (blacks) per 1,000 person years (p less than 0.005); the difference was largely explained by higher myocardial infarction rates among older (55 years or older) white men (15.6 vs. 7.5, p less than 0.05). That advantage was not present amongst younger black persons. In fact, blacks lost more years of life before age 65 (102 vs. 64 years/1,000 persons, p less than 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

Women, myocardial infarction, and dementia in the very old.

Dementia is a major public health problem among the very old. Available information on incidence and prevalence is sparse and variable; however, there appears to be a higher prevalence among very old women. We present data from a prospective study of initially nondemented community-residing elderly. There were 75 incident dementia cases (up to 7 years of follow-up) of which at least 47% were probable Alzheimer's disease. Based on a proportional hazards analysis, women were over 3 times more likely to develop dementia than men despite controlling for baseline demographic, psychosocial, and medical history variables. Poor word fluency and a high normal Blessed test score at baseline were also strong predictors of dementia. We did not find age, head trauma, thyroid disease, or family history of dementia to be risk factors. A new finding is that history of myocardial infarction (MI) is associated with dementia, such that women with a history of MI were 5 times more prone to dementia than those without a history. This observation was not true for men.

The association between orthostatic hypotension and recurrent falls in nursing home residents.

PURPOSE: Orthostatic hypotension is common among the elderly, but its relation to falls is not certain. We determined whether orthostatic hypotension, including its timing and frequency, was associated with falls in elderly nursing home residents. SUBJECTS AND METHODS: We conducted a prospective study of 844 elderly (60 years of age and older), long-stay residents at 40 facilities that were part of a multistate nursing home chain. All subjects were able to maintain weight-bearing for at least 1 minute. Orthostatic hypotension was defined as a 20 mm Hg or greater decrease in systolic blood pressure from supine to standing, as measured after 1 or 3 minutes of standing on four occasions (before or after breakfast, or before or after lunch). The outcome was any subsequent fall during a mean of 1.2 years of follow-up. RESULTS: Orthostatic hypotension was present (at least on one measurement) in 50% of the subjects but was not associated with subsequent falls. However, among subjects with a history of previous falls in the past 6 months, those with orthostatic hypotension had an increased risk of recurrent falls [adjusted relative risk (RR) = 2.1; 95% confidence interval (CI), 1.4 to 3.1 ]. The risk of subsequent falls was greatest in previous fallers who had orthostatic hypotension at two or more measurements (RR = 2.6; 95% CI, 1.7 to 4.6). The association between orthostatic hypotension and recurrent falls was independent of measured demographic or clinical risk factors for falls. The timing of orthostatic hypotension (before or after meals) did not affect the risk of falls. CONCLUSIONS: Orthostatic hypotension is an independent risk factor for recurrent falls among elderly nursing home residents. Although the benefit of treating orthostatic hypotension will require further study, it may be prudent to identify high-risk residents and institute precautionary measures.

Prevalence, incidence and prognosis of recognized and unrecognized myocardial infarction in persons aged 75 years or older: The Bronx Aging Study.

The prevalence, incidence and prognosis of recognized and unrecognized Q-wave myocardial infarction (MI) was assessed in an 8-year prospective study of 390 community-based subjects (age 75 to 85 years at entry, mean 79 years). Subjects were studied at baseline and with annual follow-up electrocardiographic (ECG) exams. At baseline, 7.9% had a history of MI without ECG evidence, 6.4% had ECG evidence of Q-wave MI without clinical history, 4.1% had both clinical history and ECG evidence and 81.5% had neither history nor ECG evidence (control subjects). After an average follow-up period of 76.2 months, the total mortality rate was 5.9/100 person-years for subjects with some evidence of MI at baseline versus 3.9 in the control group (p = 0.059). The incidence of cardiovascular disease in subjects with evidence of MI was 8.8/100 person-years versus 4.7 among control subjects (p = 0.002). During the follow-up period, 115 new Q-wave MIs occurred (50 unrecognized, rate 2.4/100; 65 recognized, rate 3.2/100). There was no difference in mortality and morbidity outcome between subjects with recognized and unrecognized MIs. Those with only a history of MI at baseline had a threefold greater risk of a new MI (recognized and unrecognized) than the control group (p = 0.003). Unrecognized Q-wave MI is a common occurrence in the "old old" with subsequent morbidity and mortality prognosis comparable to that of recognized MI. History of MI alone in this age group is also associated with an increased risk of MI, suggesting the need for better diagnostic markers of myocardial ischemia in the old.

Serum lipids and lipoproteins in advanced age. Intraindividual changes.

The Bronx Aging Study is a longitudinal investigation of nondemented, nonterminally ill, community-residing, old old volunteer subjects, designed to assess risk factors for the development of dementia and coronary and cerebrovascular diseases. During the first five annual evaluations, total cholesterol, high-density (HDL) and low-density lipoprotein (LDL), and triglyceride levels were measured. Mean cholesterol values (+/- standard error of the mean) for subjects at baseline were significantly higher for women than for men. Respectively, the values for total cholesterol were 6.1 +/- .1 mm/L (234 +/- 3 mg/dL) and 5.3 +/- .1 mm/L (207 +/- 3 mg/dL); for LDL cholesterol, 4.1 +/- .1 mm/L (158 +/- 2 mg/dL) and 3.7 +/- .1 mm/L (141 +/- 3 mg/dl); and for HDL cholesterol, 1.2 +/- .1 mm/L (47 +/- 1 mg/dL) and 1.0 +/- .1 mm/L (38 +/- 1 mg/dL). Mean triglyceride levels were 1.5 +/- .1 mm/L (135 +/- 5 mg/dL) for women and 1.6 +/- .1 mm/L (138 +/- 5 mg/dL) for men. Further, mean values remained stable over time. However, there was considerable intraindividual change observed in a substantial proportion of subjects between initial and final determinations. Changes of at least 10% from baseline were observed in 41%, 63%, 52%, and 78% of the cohort for cholesterol, HDL, LDL, and triglycerides, respectively. Thus, single measurements appear inadequate for establishing a diagnosis of hyperlipidemia in the elderly.

Intra-individual postural blood pressure variability and stroke in elderly nursing home residents.

Orthostatic hypotension (OH) is a potential risk factor for adverse cardiovascular events, but OH is highly variable and may not be detected on a single occasion. To assess the relation between intra-individual variability of systolic orthostatic blood pressure change (DeltaSBP) and cardiovascular outcomes, an algorithm was developed to identify DeltaSBP instability using repeated supine and standing BP measurements. A cohort of 673 nursing home residents underwent baseline postural BP measurements (supine to 1 minute of standing, four times in a single day) and were followed for up to 2 years. Two groups (stable vs. unstable) were identified based on an analysis of DeltaSBP variance components. Differences in outcomes were compared via Cox survival analysis. At baseline 12.6% were unstable, defined as a one standard deviation difference of at least 20.2 mmHg between DeltaSBP readings. Unstable subjects were more likely to have OH on at least one measurement (systolic BP drop of 20 mmHg or more; 85% vs. 36%, respectively) and to be on psychotropic medication at baseline (47% vs 35%) (P-values <0.001). Other characteristics (including previous stroke) did not differ. During a mean follow-up of 10.3 months, stroke incidence was higher in unstable subjects (13.1% vs. 4.9%; P = 0.012), but ischemic heart disease and mortality rates were not significantly different (respectively, 13.5% vs. 7.4%, P = 0.115; 14.8% vs. 10.7%, P = 0.178). Survival analyses (adjusted for age, sex, psychotropic medications, body mass index, ischemic heart disease, and supine systolic pressure) confirmed a higher risk of stroke in unstable subjects (relative risk = 3.7, 95% CI: 1.6-8.4). Highly variable orthostatic BP measures may reflect impaired BP regulatory mechanisms in elders with occult cerebrovascular disease, or may directly affect cerebral blood flow. Orthostatic BP variability may be a better indicator of future stroke than a single supine or orthostatic change measure.

Blood pressure reactivity predicts myocardial infarction among treated hypertensive patients.

High blood pressure (BP) defines a prognostically heterogeneous group. Because BP varies according to time, setting and means of observation, it has been postulated that BP reactivity might better predict cardiovascular disease (CVD) than does unidimensional measurements. To assess BP reactivity, the difference between pretreatment nurse (RN) and physician (MD) diastolic BP (DBP)--systematically recorded in that order--or MD-RN DBP, was obtained in 1737 previously untreated patients with sustained, RN BP greater than or equal to 160 and/or 95 mmHg. Patients stratified by tertiles of MD-RN DBP [(I) less than or equal to - 3, (II) -2 to 3 and (III) greater than or equal to 4 mmHg] were similar by sex, race, age, body mass index, cholesterol, electrocardiography, prior CVD, smoking and pretreatment or attained in-treatment BPs. During 14 years of followup, myocardial infarction (MI) incidence per 1000/year were, tertile I (3.2), II (3.7), III (7.6) (relative risk = 2.4, III vs I + II, p less than 0.05), whereas stroke incidence and non-CVD mortality were evenly distributed. By Cox survival analysis, controlling for other entry characteristics only age, sex and DBP reactivity remained predictive (p less than or equal to 0.03) of MI or total CVD. Thus, BP reactivity, probably a centrally-mediated phenomenon, identifies a subgroup of hypertensives with an increased propensity for MI despite successful BP control.

Development, testing, and validation of two scales measuring nursing home management of subjects with mental disorder.

This paper describes the development, testing, and validation of summary scales measuring nursing processes commonly used in caring for elderly nursing home residents with cognitive, mood, and behavior problems, or other markers of mental disorder. Data were obtained from a cross-sectional study of 1017 residents from a proportionate random sample in Delaware nursing facilities, to determine the prevalence of mental disorders and to describe distinguishing characteristics and treatments. An exploratory factor analysis was performed on 11 frequently encountered nursing management strategies as applied to 808 subjects with some indicator of mental disorder. Two factors emerged, which were subsequently conceptualized as separate scales (composed of six and five elements, respectively) that measure the basic approaches termed Encouragement and Control. Alpha reliability levels determined internal consistency for each scale. Cognitive, behavioral, and mood correlates were identified for each scale using multiple regression. Replication and validation were achieved when similar findings were obtained using a random sample of 290 residents at Hebrew Rehabilitation Center for Aged, a 725-bed long-term care facility in Boston. LISREL analyses confirmed the presence of at least two dimensions in behavior management strategies. The identification of these approaches is significant in providing non-pharmacologic and non-restraint alternatives to managing elderly residents with symptom distress.

Longitudinal weight changes, length of survival, and energy requirements of long-term care residents with dementia.

OBJECTIVE: We hypothesized that institutionalized patients with dementia, who frequently have feeding problems and require supervised and assisted feeding, would lose more weight during their residency than nondemented, independently functioning residents and have compromised survival. To test this hypothesis, we examined the survival and longitudinal changes in weight of two cohorts of institutionalized residents with dementia and compared these cohorts with a cohort of nondemented residents. We also measured the resting energy expenditures of a subset of the subjects with dementia as an indicator of their energy needs. DESIGN: A longitudinal cohort study with retrospective baseline chart review and subsequent follow-up of monthly weights and mortality over 4 years. SETTING: A 725-bed long-term care institution with specified levels of care. SUBJECTS: Two cohorts of residents with dementia, one consisting of subjects who required total care throughout their institutional stay (n = 31) and another group who did not initially require total care (n = 48); these were compared with a cohort with normal mentation who were functionally independent in their daily activities (n = 26). The total number of subjects was 105. MEASUREMENTS: Demographics, medical problems, and medications by chart review; functional and mental status evaluations; longitudinal monthly weights and mortality for the 48-month study period; and resting energy expenditures by indirect calorimetry. MAIN RESULTS: Residents with dementia had lower weights on admission and throughout their stay than nondemented, independently functioning residents, and they were more likely to have a weight loss of 10 lbs or more at some point during the 4-year study period. However, their mean weights did not change during the study period. The mean survival from admission of those demented residents who died was more than 3 years. Resting energy expenditures of women residents with advanced dementia were 12% lower than predicted from the Harris Benedict equations. CONCLUSION: Dementia is not necessarily associated with unremitting weight loss during institutionalization despite the frequent occurrence of feeding difficulties and temporary weight loss. This may be caused partly by the lower than expected resting energy expenditures and, hence, energy needs of affected residents as their dementia progresses. Demented residents weighed significantly less than nondemented, independently functioning residents throughout their institutional stay. Nevertheless, nursing staff are able to maintain weight and survival for extended periods even in very impaired residents.

Blood pressure behavior in the nursing home: implications for diagnosis and treatment of hypertension.

OBJECTIVES: To determine patterns of elevated blood pressure (BP) behavior, their clinical correlates, and the relationship to diagnosis and management of hypertension. DESIGN: A cross-sectional, prevalence survey. SETTING: Forty-five nursing homes owned or managed by a large national chain. PARTICIPANTS: A total of 857 older residents (mean age = 84 years). MEASUREMENTS: Supine and standing (1 and 3 minutes) BP and heart rate, taken four times in one day (before and after breakfast, and before and after lunch) by trained nurses using a random zero sphygmomanometer; medication profile; active medical diagnoses; functional status; sociodemographics. RESULTS: The prevalence of a single, elevated, supine systolic pressure (> or = 160 mm Hg) was 14.3%, and of two to four elevated measures was 14.9%. The pre-breakfast reading was consistently the highest, and mean systolic pressures decreased after breakfast. Compared with those not treated, older residents taking antihypertensive medications had higher systolic pressures at all times and showed the same pattern of decline after breakfast. Isolated diastolic hypertension was uncommon (0.9%). Cardiovascular disease, orthostatic hypotension, diabetes, and use of angiotensin converting enzyme inhibitors or calcium channel blockers were more prevalent among older residents who had elevated pressures on multiple occasions (P < .03). Successful antihypertensive treatment was associated with a lower prevalence of orthostatic hypotension. Diuretic use was more likely to be associated with blood pressure control. CONCLUSION: The diagnosis of hypertension in frail older people would benefit from multiple, within-day measures, including postural BP, taken before and after meals. Diuretic use alone, or in conjunction with ACE inhibitors or calcium channel blockers, was more likely to be associated with normalized blood pressures.

The relationship between age, gender and cognitive performance in the very old: the effect of selective survival.

OBJECTIVE: To determine the prevalence of cognitive disability as a function of advanced age and gender in elderly nursing home and community-dwelling populations. Since cognitive dysfunction is associated with increased mortality, we hypothesized that selective survival results in a decreased prevalence of cognitive disability in the oldest old. DESIGN: Cohort study. An analysis of 6-month longitudinal data obtained from a national probability sample of older persons in 260 nursing homes (n = 1951) and 2-year-longitudinal data obtained from a sample of community-dwelling older persons (n = 2947). MEASURES: In the nursing home sample, the primary outcome measure was cognitive performance score. In the community sample, cognitive performance was determined using the results of three orientation questions and assessment of decision-making ability. Cognitive performance and subsequent survival, controlling for various disease states and demographic factors, were examined in three age cohorts of men and women (ages 65-79, 80-89, 90-99). RESULTS: In the nursing home sample, the cognitive performance of very old men (> or = 90 years) was better than that of younger men (aged 80-89 years, P < 0.05) and very old women (age > or = 90 years, P = 0.001). Among 80-89-year-olds with poor cognitive performance, the 6-month mortality rate was higher in men than in women (38% vs 19%, P = 0.001). However, the mortality rates of men and women with good cognitive performance were not statistically different in any age group. Proportional-hazards regression analysis demonstrated that poor cognitive performance remained a powerful predictor of death among men aged 80-89 years with a relative risk of 2.7 (95% Cl, 1.19-3.17; P = 0.0006) after controlling for covariates. Results from the community sample lent support to our findings: within each age group, mortality rates for men and women with intact cognitive performance were not statistically different. However, in the two older age groups, the mortality rates of subjects with impaired cognitive performance were significantly greater for men than for women (P < 0.01 for both age groups). CONCLUSIONS: Decreased cognitive performance is significantly associated with mortality among elderly men. Survival by men who have relatively intact cognitive function results in a population of oldest men, those aged 90-99 years, with cognitive performance scores better than younger men or similarly-aged women. The same selective survival phenomenon was not observed among women. Thus, there may be less cognitive disability among very old men than previously expected.

A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes.

OBJECTIVE: To determine risk factors associated with the formation of stage II-IV pressure ulcers in nursing homes. DESIGN: Since the incidence rate for pressure ulcer formation varies among nursing homes, the homes were divided into tertiles based on these rates. Pooled logistic regression was used to model which factors are associated with the formation of pressure ulcers in both high and low incidence homes. SETTING: 78 National HealthCorp nursing homes. SUBJECTS: We studied 4232 nursing home residents free of pressure ulcers on admission to a nursing facility and at 3-months follow-up. All remained in the home for at least 3 additional months to a maximum of 21 months. MEASUREMENTS: The effects of age, gender, race, antipsychotic drug use, urinary incontinence, fecal incontinence, body mass index, diabetes mellitus, disorientation, ambulation, physical restraints, activities of daily living of bathing, feeding, or transferring, and nursing home bed size on the formation of a stage II-IV pressure ulcer while the subject was a resident in the nursing home were studied. MAIN RESULTS: Significant factors associated with the formation of pressure ulcers in high incidence homes (21-month incidence = 19.3%) were ambulation difficulty (OR = 3.3; CI = 2.0, 5.3), fecal incontinence (OR = 2.5; CI = 1.6, 4.0), diabetes mellitus (OR = 1.7; CI = 1.2, 2.5), and difficulty feeding oneself (OR = 2.2; CI = 1.5, 3.3). In the low incidence homes (21-month incidence = 6.5%), significant factors associated with pressure ulcer incidence were ambulation difficulty (OR = 3.6; CI = 1.7, 7.4), difficulty feeding oneself (OR = 3.5; CI = 2.0, 6.3), and male gender (OR = 1.9; CI = 1.2, 3.6). CONCLUSIONS: Although low and high incidence homes share similar risk factors, such as ambulation and feeding activities of daily living, the main difference was that diabetes and fecal incontinence played a major role only in high risk homes, while male gender was an important discriminator only in low incidence homes. Yet, it is unclear if these factors explain the three-fold difference in the incidence rates for pressure ulcers in these facilities. Baseline or resident clinical characteristic differences of any one factor between the high and low incidence homes varied by no more than 5%. While we identified certain conditions which are associated with pressure ulcer formation, there may be unknown or unmeasured facility effects in addition to the characteristics of a given resident in a particular home.

Hypertension: cardiovascular implications in a cohort of old old.

OBJECTIVE: To examine the prevalence and cardiovascular implications of hypertension in advanced age. DESIGN: Prospective non-interventional study of a fixed cohort of very elderly subjects. PARTICIPANTS AND SETTING: The subjects were 488 community-dwelling volunteers. Mean age at entry was 79 years (range 75-85). All subjects were ambulatory, non-demented, and free of terminal illness at baseline. Participants were evaluated at the gerontology department of an urban medical school. MAIN OUTCOME MEASURES: Cardiovascular morbid and mortal events that were followed included fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, and death. Prevalence of unrecognized myocardial infarction defined by electrocardiographic changes was also assessed. RESULTS: When hypertension was defined by history, current use of medications, or measured elevations in blood pressure, 78% of the subjects could be considered hypertensive. Univariate analysis showed an increased incidence of strokes in subjects with measured hypertension (P = 0.04). Subjects with elevated blood pressure (untreated) were more likely to develop clinically unrecognized myocardial infarction (P = 0.017). Multivariate survival analysis showed hypertension to be a modest predictor of overall cardiovascular disease (P = 0.067) but not of all-cause mortality. Left ventricular hypertrophy was a predictor of cardiovascular disease (P = 0.013) and all-cause mortality (P = 0.008). Age remained a significant risk factor for these endpoints, even in the very old. Isolated systolic hypertension was analyzed separately and in univariate analysis was a risk factor for stroke but not other cardiovascular morbidity. CONCLUSIONS: Hypertension at advanced age remains a modestly important risk factor in the development of cardiovascular disease.

Left ventricular hypertrophy on electrocardiogram: prognostic implications from a 10-year cohort study of older subjects: a report from the Bronx Longitudinal Aging Study.

OBJECTIVE: The objective of this study was to report on the prevalence, incidence and prognosis of left ventricular hypertrophy (LVH) on the electrocardiogram (ECG) in a cohort of ambulatory older men and women. DESIGN: A prospective, longitudinal study of 10 years duration with ECGs obtained at baseline and on an annual basis. SETTING AND PATIENTS: A community-based cohort study consisting of 459 subjects (aged 75-85, mean age 79 years). MEASUREMENTS: Baseline and follow up ECGs were interpreted using the Minnesota Code. Prevalence and incidence of LVH and ECG were determined as well as regression of ECG LVH. Clinical event rates measured were incidence of total mortality, myocardial infarction (MI, fatal and non-fatal), cardiovascular mortality, cardiovascular disease (fatal and non-fatal), stroke (fatal and non-fatal), all-cause dementia, and multi-infarct dementia. Differences in event rates between groups (those subjects with and without LVH) were compared as tests between proportions. A Cox Proportional Hazards Regression Analysis was performed to compare the relative independent predictive values of different competing factors, including age, gender, serum cholesterol, digitalis use, body mass, index, Blessed Dementia Scale, cigarette smoking, LVH at baseline, LVH ar baseline (persisting), new LVH, new LVH (persisting), new LVH (regressed), previous MI by history of ECG, hypertension by history, and cardiomegaly by X-ray (cardiothoracic ratio > or = 50%). RESULTS: At baseline, 9.2% of subjects (n = 42) had LVH on ECG and a mortality rate of 11.7/100 persons years versus 4.9/100 persons years for subjects without baseline LVH (P < .0001), and MI rate of 7.5/100 persons years with LVH versus 2.6/100 persons years without LVH (P < .0001), and a cardiovascular mortality rate of 7.2/100 persons years without LVH versus 2.7/100 person years without LVH. Subjects who developed new LVH on ECG (n = 39) had a mortality rate of 14.4/100 person-years compared with 4.4/100 person-years for those without LVH (P < .0001), a cardiovascular mortality rate of 11.1/100 person years versus 2.0/100 person years without LVH (P < .0001), and an MI rate of 6.1/100 person years versus 2.0/100 person years without LVH (P < .01). Subjects in whom the ECG LVH pattern disappeared over time had fewer cardiovascular mortal and morbid events than those with persistent LVH. According to the regression analyses, persistent LVH from baseline was an independent predictor of MI, overall cardiovascular disease, and total mortality. Newly developing LVH with subsequent regression was an independent predictor of overall cardiovascular disease and death. CONCLUSIONS: An increased prevalence and incidence of LVH on ECG, irrespective cause, is associated with a poor prognosis in very old men and women. Regression of ECG LVH in older people, irrespective of cause, may confer improvement in risk for cardiovascular disease.

The effect of specific medical conditions on functional decline.

OBJECTIVES: To examine how functional status among older community-dwelling residents differs over time between those with and those without specific medical conditions. DESIGN: Prospective cohort study. PARTICIPANTS: A total of 1060 community-dwelling Massachusetts residents aged 65 or older who were not totally functionally dependent at baseline assessment. MEASUREMENTS: Functional status, five medical conditions (heart problem, arthritis, diabetes, cancer, and stroke), and the total number of these five medical conditions. Assessments were done at baseline and at two annual follow-ups. RESULTS: Adjusted repeated measures analysis of covariance revealed a time difference (P < .001) for all five medical conditions and group differences for diabetes (P = .006) and stroke (P < .001). Functional abilities declined over time and those with specific medical conditions were more impaired initially, but the rate of decline did not significantly differ from those free of the condition. The presence of each additional medical condition resulted in additional impairment (P < .001), but the rate of decline over time did not differ by number of medical conditions. CONCLUSIONS: Efforts to reduce or prevent the development of specific medical conditions are essential to maintaining functional independence of older people as well as to reducing use of supportive services and admission rates to nursing homes. Particular attention should be directed toward preventing stroke since its consequences are the most functionally disabling.