Race and sex differentials in the impact of hypertension in the United States. The National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study.

Hypertension was evaluated longitudinally in a nationally representative sample of the US population. This study, based on the data from the National Health and Nutrition Examination Survey NHANES I Epidemiologic Follow-up Study, analyzed changes in blood pressure and frequency of treatment, hypertension incidence, and ten-year survival of the cohort relative to hypertension status at baseline. Higher prevalence rates for each older age group, especially in women, as previously reported on data from community studies were confirmed. However, this analysis found minimal differences in the incidence of hypertension between men and women for all age groups. Incidence rates for blacks were at least twice the rates for whites for almost every age-sex group. Decreased survival in older hypertensive men probably explained the higher prevalence in older women. Treatment and location of measurement in clinic or household must be major considerations in the calculation of incident cases.

A comparison of patients with spondyloarthropathy seen in specialty clinics with those identified in a communitywide epidemiologic study. Has the classic case misled us?

BACKGROUND: Undiagnosed cases of seronegative spondyloarthropathy (Spa) are often observed during epidemiologic studies. OBJECTIVE: To determine the extent of and the reasons for the underdiagnosis of Spa. METHODS: We studied 2 groups of Alaskan native patients with Spa using a standardized protocol that included an interview, physical examination, medical record review, and radiographic and laboratory examinations. One group consisted of patients identified in a communitywide epidemiologic study; the other group consisted of patients from related but geographically separate populations who had been diagnosed by a specialist in the hospital or a specialty clinic. All cases met the current classification criteria for Spa. The clinical and demographic features of the cases in the 2 groups were compared. RESULTS: Fifty-five (72%) of the 76 community cases that we identified in the epidemiologic study had not been diagnosed previously as Spa. Among the undiagnosed patients were 34 (94%) of the 36 women, 11 (65%) of the 17 patients with ankylosing spondylitis, 12 (36%) of the 33 patients with reactive arthritis, and 24 (100%) of those with undifferentiated Spa. The community and specialty clinic patient groups were similar in age of onset of joint and back pain and in overall symptoms. The specialty clinic group had a higher proportion of men, more severe disease, and a higher frequency of iritis. CONCLUSIONS: The diagnosis of Spa was missed more often than not in the primary care setting, probably because most of the cases were of mild or moderate severity and did not fit the classic descriptions of spondyloarthropathic disorders. The higher proportion of men among the specialty clinic cases probably reflects provider expectation as well as a slightly milder disease course in women.

Discrepancies between patient recall and the medical record. Potential impact on diagnosis and clinical assessment of chronic disease.

BACKGROUND: During a case-control study, data necessary for fulfilling diagnostic and classification criteria for spondyloarthropathy were collected from 121 patients. OBJECTIVE: To study the potential impact of differences between patient recall and the medical record on diagnosis and clinical characterization of spondyloarthropathy as a model of chronic disease. METHODS: The study was conducted among four Alaskan Eskimo populations served by the Alaska Native Health Service. Two sets of historical data were compiled for each subject, one acquired during the interview and the other derived from the medical record. Paired items from the interview and the medical record were analyzed to determine discrepancies and consequent effects on diagnosis, classification, and disease characterization. RESULTS: Significant differences were observed in the reporting of genitourinary or diarrheal illnesses preceding or associated with arthritis, the occurrence of eye inflammation in association with joint pain, the occurrence of joint pain and back pain together, and the age at onset of back pain all of which are important to the diagnosis and classification of spondyloarthropathy. In contrast, for information needed to establish the probable inflammatory nature of back pain, patient interview was more helpful than the medical records, which did not provide adequate details to differentiate inflammatory from mechanical back pain. CONCLUSIONS: Patient recall bias can substantially affect diagnosis and clinical assessment of chronic disease, as exemplified by spondyloarthropathy. Reliance on records alone, however, may lead to underestimation of features that require subjective appraisal by the patient.

Blood pressure in childhood. The National Health Examination Survey.

Data were analyzed from the U.S. Health Examination Survey (Cycle II) to determine relationships between blood pressure and other characteristics. This survey examined a national probability sample of children aged 6-11 years. Significant relationships were found for blood pressure and the following variables: chronological and skeletal age, skinfold thickness (adiposity) and other anthropometric measurements, pulse rate, and systolic murmurs. These relationships may be interpreted as indicating important relationships between blood pressure and growth, adiposity, and hemodynamic manifestations of cardiac output. Data from this representative population portray blood pressure relationships in childhood.

Blood pressure in adolescence. The United States Health Examination survey.

A nationally representative sample of adolescents 12-17 years of age were examined in the U.S. Health Examination Survey and relationships between blood pressure and other variables were explored. During adolescence, blood pressure increases more rapidly in males than in females and only small racial differences are present. Weight has the strongest relationship to both systolic and diastolic pressure. Physiological maturation assessed by skeletal age and adiposity (skinfold thickness) are components of weight and each is also related to blood pressure. Although systolic murmurs are related to blood pressure at the time of examination, the murmurs are transitory and not predictive of future pressures. All factors were equally influential in each race-sex group. No significant relationships were found between geographic or demographic variables and blood pressure. These observations indicate the important relationships of physiological maturation and adiposity to adolescent blood pressure.

Antihypertensive drug therapy and survival by treatment status in a national survey.

The National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study, an investigation of a cohort originally examined during the period 1971-1975, provided an opportunity to assess the frequency of antihypertensive drug therapy in the United States during the period 1982-1984. For most age-sex-race subgroups, the frequency of medication use during 1982-1984 was higher than that observed during 1976-1980 based on the NHANES II. In the interval 1982-1984, diuretic agents were the most frequent medications prescribed (47% of drugs prescribed), and beta-blockers were second (17%). At the time of the initial survey in 1971-1975, participants had their blood pressures measured and a history of diagnosis and treatment of hypertension ascertained. Follow-up for vital status was 93% complete by 1984 (average length of follow-up, 9 years). In white men and women aged 50 years and older, the relative risk of death increased steadily, from those with elevated blood pressure (systolic blood pressure greater than or equal to 160 mm Hg or diastolic blood pressure greater than or equal to 95 mm Hg) but no history of hypertension to those treated for hypertension but whose blood pressure was still elevated. Regardless of history or treatment, those with an elevated blood pressure had about a 25-30% excess risk of death. Evidence from these national studies shows a high frequency of antihypertensive drug therapy in 1982-1984 and suggests the importance of adequate blood pressure control for optimal survival.

Physiologic determinants of serum urate levels in adolescence.

During adolescence, serum urate increases and adult levels are achieved. Physiologic factors related to serum urate were investigated in a nationally representative population of 6,768 youths aged 12 to 17 years (the US Health Examination Survey). Serum urate concentration increases markedly from ages 12 to 14 years in males, and levels were related to sexual and skeletal maturation. Although similar relationships were observed in females, the association is less striking, probably because of earlier pubescence, which was not captured in this study, and a pronounced androgenic response. In the later stages of adolescence (ages 15 to 17 years for males and 13 to 17 years for females), body composition (body mass index and skinfold thickness), blood pressure, and hematocrit have stronger relationships than sexual and somatic maturation. These latter relationships are similar to those in adults. This survey affords a portrayal of physiologic interrelationships with serum uric acid during adolescence.

Electrocardiographic estimate of left ventricular mass versus radiographic cardiac size and the risk of cardiovascular disease mortality in the epidemiologic follow-up study of the First National Health and Nutrition Examination Survey.

The prognostic value of a left ventricular (LV) mass index (g/m2) estimated from an electrocardiographic model and radiographic estimates of the relative heart volume (ml/m2) and cardiothoracic ratio for predicting the risk of cardiovascular disease mortality were investigated using Cox regression analysis to adjust for age, systolic blood pressure and history of heart attack in 1,807 men (1,609 white, 198 black) and 2,143 women (1,884 white, 259 black). The study population (ages 35 to 74 years at baseline) was followed from 5 to 12 years (average 9.5 years) for cardiovascular disease mortality. LV mass index and relative heart volume were independent predictors of cardiovascular disease mortality among white men. All 3 cardiac size estimates were independent predictors for cardiovascular disease mortality among white and black women. When LV mass index was used as a dichotomized variable to indicate the presence or absence of LV hypertrophy, the age-adjusted relative risk of cardiovascular disease mortality was 2.48 (95% confidence interval 1.77 to 3.46) for white men, 3.03 (1.49 to 6.16) for black men, 1.86 (1.21 to 2.87) for white women and 2.05 (0.83 to 5.05) for black women. The corresponding prevalence of LV hypertrophy was 15.4% for white men, 36.6% for black men, 20.1% for white women and 17.4% for black women. It is concluded that the electrocardiographic estimate of LV mass index can identify a substantially larger fraction of persons at increased risk for cardiovascular mortality than conventional electrocardiographic criteria for LV hypertrophy and that LV mass index estimated by electrocardiogram is a valuable supplement to radiographic cardiac size estimates in epidemiologic applications.

Are sleep complaints an independent risk factor for myocardial infarction?

PURPOSE: To investigate whether subjective sleep complaints are an independent predictor of myocardial infarction (MI) in a community of older adults and to gain clues as to why the association between sleep complaints and incident MI exists. METHODS: Using longitudinal data from the Piedmont study on 2960 adults aged 65 or older who were free of symptomatic heart disease at baseline, we screened 19 potential confounders to determine if any, alone or in combination, could explain the observed relationship between incident MI and sleep complaints. RESULTS: During the three-year follow-up period, there were 152 incident MIs. Restless sleep (incidence density ratio (IDR) = 1.58, 95% confidence interval (CI) = 1.11, 2.24) and trouble falling asleep (IDR = 1.68, 95% CI = 1.09, 2.60) predicted incident MI after adjusting for age, gender, and race. IDRs were not substantially impacted by controlling for smoking, blood pressure, diabetes or obesity. After adjustment for education, number of prescription medicines, self-rated health, and depression score, all IDRs were nullified. In particular, self-rated health and depression were strong independent risk factors for MI. CONCLUSIONS: A subjective sleep complaint increases the likelihood of a first MI in older adults without overt coronary heart disease (CHD) independently of classic coronary risk factors and appears to be a marker for a syndrome of depression and malaise that may have a causal relationship to MI.

Serum albumin in older persons: relationship with age and health status.

We analyzed data from 4115 persons aged 71 years and older who had blood drawn at a home visit in three communities to examine the cross-sectional distribution of serum albumin and correlates of hypoalbuminemia. Mean albumin was lower among older persons, from 41.6 g/l in men aged 71-74 years to 38.5 g/l in men 90 years or older, and from 41.1 g/l to 38.9 g/l in women of the same ages, respectively. Hypoalbuminemia (albumin less than 35 g/l) was observed in 3.1% of subjects. Hypoalbuminemia and lower serum albumin were independently associated with anemia, recent diagnosis of cancer, two or more limitations in activities of daily living, residence in a nursing home, heavy cigarette smoking (greater than 1 pack/day), and older age. A 10-year age increment was associated with 0.8 g/l lower serum albumin and odds ratio of 1.56 (95% CI 1.14, 2.13) for hypoalbuminemia after adjusting for demographic factors and health status. Characteristics associated with serum albumin may confound the reported relationship between serum albumin and mortality.

An overview of body weight of older persons, including the impact on mortality. The National Health and Nutrition Examination Survey I--Epidemiologic Follow-up Study.

The authors studied distributions of body weight for height, change in body weight with age, and the relationship between body mass index and mortality among participants in the Epidemiologic Follow-up Study of the first National Health and Nutrition Examination Survey (NHEFS) (n = 14,407), a cohort study based on an representative sample of the U.S. population. Percentiles of body weight for height according to age and sex are presented. Cross-sectional analyses of body weight suggest that mean body weight increases with age until late middle age, then plateaus and decreases for older aged persons. However, longitudinal analysis of change in weight with age shows that younger persons in the lower quintile at baseline tend to gain more than those in the higher quintile. Older persons in the higher quintile at baseline have the greatest average loss in weight. The relationship of body mass index to mortality is a U-shaped curve, with increased risks in the lowest and highest 15% of the distribution. Increased risk of mortality associated with the highest 15th percentile of the body mass index distribution, as well as the highest 15% of the joint distribution of body mass index and skinfold thickness, is statistically significant for white women. However, the risk diminishes when adjusted for the presence of disease and factors related to disease. More noteworthy is the fact that there is a statistically significant excess risk of mortality for both race and sex groups in the lowest 15% of the body mass index distribution after adjusting for smoking history, and presence of disease. Those in the lowest 15% of the joint body mass index and skinfold thickness distribution, were also at increased risk. Risk of mortality for both men and women who have lost 10% or more of their maximum lifetime weight within the last 10 years is statistically significant, even when controlling for current weight. This study has replicated previously reported relationships, while correcting for several methodological issues.

Co-morbidity analysis: a strategy for understanding mortality, disability and use of health care facilities of older people.

Older people often have several co-existing health problems. The type, number, duration and severity of these problems may have an impact on longevity and maintenance of independence. Analyses of co-morbidity can assess the additive or multiplicative effect of more than one chronic condition or impairment on the risks of mortality, loss of functioning and use of health services. Three major surveys of the elderly, initiated in the past ten years, provide data for studying the added burden of multiple morbidities. These surveys are: The National Health Interview Survey-Supplement on Aging; The National Health and Nutrition Examination Survey I-Epidemiologic Follow-up Study; and The Established Populations for Epidemiologic Studies of the Elderly. Results of analyses of co-morbidity using data from these three surveys are presented. Although each analysis used a different definitional approach to estimate the co-morbidity effect, each demonstrated an associated or increased risk on the outcome.

Occurrence and predictors of pressure sores in the National Health and Nutrition Examination survey follow-up.

The occurrence of pressure sores during a follow-up period of approximately 10 years is documented for a US nationwide cohort aged 55 to 75 years at baseline. Using data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study, those who developed pressure sores were identified through death certificates, hospital discharge summaries and self-report or proxy-report. During the follow-up period, pressure sores were identified in 113 of the 5,193 respondents (2.2%) for whom follow-up information was available. Incidence over the follow-up period was 1.7% for those aged 55 to 69 at baseline and rose to 3.3% for those 70 to 75 years old. Risk factors for pressure sore development were evaluated using data collected in NHANES I at baseline. Those with identified pressure sores were compared with the remainder of their cohort and also with a control group matched on age and length of longest hospitalization or nursing home admission. Significantly increased risk for pressure sore development was found for those who at baseline were current smokers, reported being relatively inactive, had poor self-assessed health status and who were found on physician's exam to have dry or scaling skin. Neurologic abnormality on the physician's exam and anemia at baseline were also associated with increased risk of pressure sores, although these associations were of borderline statistical significance.

Nutrition and function: is there a relationship between body mass index and the functional capabilities of community-dwelling elderly?

OBJECTIVE: To determine if there is a relationship between body mass index and the ability to perform the usual activities of living in a sample of community-dwelling elderly. DESIGN: Secondary data analysis of The National Health and Nutrition Examination Survey-I Epidemiologic Follow-up Study (1982-1984). Follow-up home interview of a population-based sample originally interviewed between 1971 and 1975 in the National Health and Nutrition Examination Survey-I (NHANES-I). PARTICIPANTS: Survivors of the original NHANES-I cohort who were 65 years of age or older and who were living at home at the time of the second interview (n = 3061). Excluded were those who could not be found, refused participation, or were institutionalized (n = 220), and those without complete height and weight data (n = 194). MAIN OUTCOME MEASURE: Functional status as measured by a 26-item battery. RESULTS: Bivariate analysis revealed a greater risk for functional impairment for subjects with a low body mass index or a high body mass index. The greater the extreme of body mass index (either higher or lower), the greater the risk for functional impairment. Logistic regression analysis indicated that both high and low body mass index continued to be significantly related to functional status when 22 other potential confounders were included in the model. CONCLUSION: The body mass index is related to the functional capabilities of community-dwelling elderly. The inclusion of this simple measurement in the comprehensive assessment of community-dwelling elderly is supported.

Medication use characteristics in the elderly: the Iowa 65+ Rural Health Study.

Medication use was studied in a rural, elderly population. Household interviews were conducted of 3,467 individuals aged 65 years or older. A total of 9,955 prescription or nonprescription drugs were reported by the respondents. The overall mean number of drugs per respondent was 2.87, while 12% of all respondents were not taking any drugs. Mean prescription and overall drug use increased significantly with increasing age (P less than .001), while mean nonprescription drug use was relatively constant across age groups. Significantly more women were prescription and nonprescription drug users. Directions for scheduled daily dosing accounted for 75% of all directions. The majority of prescription and nonprescription drugs had been taken on the previous day. General practitioners accounted for more prescription drugs (39.7%) than any other medical specialty. The most frequently stated purpose was cardiovascular for prescription drugs and musculoskeletal for nonprescription drugs. The three most frequent prescription drug therapeutic categories were cardiovascular (54.7%), central nervous system (CNS) agents (11.4%), and analgesics (9.4%). For nonprescription drugs, the three most frequent therapeutic categories were analgesics (39.6%), vitamins and minerals (32.9%), and laxatives (14.1%). Implications of these findings are discussed.

Light to moderate alcohol consumption and mortality in the elderly.

OBJECTIVE: To determine whether there is a relationship of low to moderate alcohol consumption with cardiovascular mortality in the elderly. DESIGN: Prospective cohort studies with 5-year mortality follow-up. SETTING: Three populations of community-dwelling elders. PARTICIPANTS: Population-based cohorts of men and women, aged 65 or older, in three populations. Subjects with prior myocardial infarction, stroke, or cancer, as well as those lacking alcohol consumption data, were excluded from statistical analyses leaving 2,694 subjects in East Boston, Massachusetts, 2,293 subjects in Iowa, and 1,904 subjects in New Haven, Connecticut. MAIN OUTCOME MEASUREMENTS: Alcohol consumption, total mortality, cardiovascular mortality, and cancer mortality. RESULTS: Low to moderate alcohol consumption was associated with statistically significant lowered total as well as cardiovascular mortality in East Boston and New Haven. The relative risks of total mortality for low to moderate consumers of alcohol compared to those consuming no alcohol in the previous year were 0.7 (95% CI 0.6-0.8) in East Boston and 0.6 (95% CI 0.5-0.8) in New Haven. For cardiovascular mortality, the RRs were 0.6 in East Boston and 0.5 in New Haven (95% CI's exclude null). These results persisted after control for potential confounding variables. In Iowa, there were no significant differences in total or cardiovascular mortality according to alcohol consumption patterns. For cancer mortality, there were no significant associations with alcohol consumption in any of the three populations. CONCLUSIONS: These data suggest that the relationship of low to moderate alcohol consumption with reduced total and cardiovascular mortality, which are well documented in middle age, also occur in older populations.

Anemia and hemoglobin levels in older persons: relationship with age, gender, and health status.

OBJECTIVE: To determine the relationship of hemoglobin levels and anemia with age and health status in older adults. DESIGN: Survey. SETTING: Community. PARTICIPANTS AND METHODS: Hematologic tests were obtained from 3,946 adults aged greater than or equal to 71 years in three communities (East Boston, MA; Iowa and Washington counties, IA; and New Haven, CT). RESULTS: Hemoglobin level was inversely associated with age, although this was more pronounced in men than in women. The proportion anemic was equal for men and women aged 71-74 years (8.6%) and increased differentially with age, reaching 41% and 21% for men and women aged greater than or equal to 90 years, respectively. Hemoglobin and anemia were independently associated with age, race, body-mass index, smoking, cancer, hospitalization, renal insufficiency, and hypoalbuminemia. The adjusted relative odds of anemia for a 5-year increase in age was 1.5 (95% confidence interval [CI] 1.3-1.8) for men and 1.2 (95% CI 1.1-1.4) for women. CONCLUSIONS: Age is significantly associated with both hemoglobin levels and anemia, with a stronger effect in men compared with women, even after simultaneously adjusting for demographic characteristics and health status. The decline of hemoglobin and concomitant increased anemia with age is not necessarily a result of "normal aging" so the detection of anemia in an older person should prompt appropriate clinical attention.

Anthropometric indicators and hip fracture. The NHANES I epidemiologic follow-up study.

A cohort of 3,595 white women aged 40-77 years was followed for an average of 10 years during which 84 new cases of hip fracture were identified. Triceps skinfold thickness and arm muscle area measured at baseline were examined as possible risk factors for hip fracture controlling for physical activity, height, menopausal status, calcium consumption, and smoking. Of these variables only arm muscle area, triceps skinfold thickness, and activity in recreation were independent predictors of hip fracture incidence using the Cox proportional hazards model. After adjustment, the estimated relative risk of hip fracture was approximately two for an increment of each anthropometric indicator (adjusted for the other) equivalent to comparing those at the 25th percentile to those at the 75th percentile (maximum width of 95% confidence intervals, 1.2-2.9). Risk of hip fracture was approximately two-fold for persons who reported little recreational exercise compared to persons who reported much recreational exercise (95% confidence interval, 1.2-3.2). Our findings are the first evidence from a prospective study that anthropometric indicators besides body mass index may have an independent relationship to risk of hip fracture.

Impact of depressive symptoms on hospitalization risk in community-dwelling older persons.

OBJECTIVE: To determine whether depressive symptoms in older adults are associated with an increased risk for hospitalization. DESIGN: A 6 month cohort study. SETTING: Five counties in the northern Piedmont of North Carolina from the Duke University site of the Established Populations for Epidemiological Studies of the Elderly project. PARTICIPANTS: The sample included 3486 community-dwelling adults, aged 65 and older. MEASUREMENTS: Crude risk ratios for the effect of depressive symptoms on 6 month risk for hospitalization were calculated, followed by a multivariable analysis controlling for demographics and health status. RESULTS: Three hundred participants were hospitalized during the 6 month follow-up period. The crude risk ratio for the effect of depressive symptoms on hospitalization was 1.95 (95% CI = 1.47-2.58). Subgroup analysis showed significant positive risk ratios for men aged 65 to 74 and > or =75, and women aged 65 to 74. After a multivariable analysis, however, these associations remained significant only among men > or =75 (RR = 3.43; 95% CI = 1.33-8.86). CONCLUSIONS: Depressive symptoms were independently associated with a more than threefold increased risk for hospitalization among men aged > or =75. This result reflects differences in the effects of depressive symptoms across age and gender groups, and emphasizes that symptoms of depression influence overall health and medical utilization among, at the very least, the oldest subset of men.

Comorbidity of five chronic health conditions in elderly community residents: determinants and impact on mortality.

BACKGROUND: Comorbidity is common in elderly persons. Its extent, correlates, and life-threatening impact in representative community residents are unclear. METHODS: Self-reported information of physician-diagnosed coronary artery disease (CAD), cerebrovascular disease (CVD), diabetes, and cancer was obtained annually between 1986-87 and 1992-93, and hypertension was obtained triennially from the participants of the Duke Established Populations for Epidemiologic Studies of the Elderly, a stratified multistage sample of 4,126 Black and White community residents aged 65-100, living in a five-county area of North Carolina. Date of death was obtained from death certificates identified through search of the National Death Index. Statistical procedures included descriptive statistics, logistic regression, and survival analysis. RESULTS: Of this sample, 57% reported hypertension, 20% diabetes, 15% CAD, 9% cancer, and 9% CVD; 29% reported none of these conditions, whereas 29% reported two or more. Demographic characteristics were not related to comorbidity with CVD or cancer. Increased education tended to be protective. The effect of age, gender, and race varied with condition. At baseline there was substantial comorbidity among hypertension, CAD, CVD, and diabetes, but not with cancer. Hypertension, CVD, and diabetes were risk factors for CAD, whereas diabetes was a risk factor for CVD. After controlling for demographic characteristics, all health conditions except hypertension were predictive of 6-year mortality, as was the presence of comorbidity. CONCLUSION: We found significant comorbidity in older persons who have hypertension, CAD, CVD, or diabetes; particular risk of developing comorbidity, particularly CAD, among those with hypertension, CVD, and diabetes; and risk of CVD in those with diabetes. With the exception of hypertension, these conditions, and comorbidity per se, are life-threatening.