The short IQCODE as a predictor for delirium in hospitalized geriatric patients.

BACKGROUND: Delirium is a serious complication, which occurs frequently in older patients with pre-existing cognitive impairment. There is a need for a simple tool to assess chronic cognitive impairment and the associated risk of delirium during hospitalization. AIMS: To assess the usefulness of the short IQCODE questionnaire in predicting delirium during hospitalization in older patients in a geriatric ward. METHODS: A prognostic study in the Geriatric Department at Aarhus University Hospital, Aarhus Denmark. Consecutive patients were enrolled during March to December, 2017. After consent of the patient, the staff interviewed the relatives by phone using the short IQCODE questionnaire. Delirium was assessed morning and evening until discharge by the Confusion Assessment Method. The ability of short IQCODE to predict delirium was examined. RESULTS: Three hundred and fifty-three patients were eligible, and 306 completed the IQCODE. Delirium occurred among 19% of the patients during hospitalization. The IQCODE score was associated with the risk of delirium with a receiver operating characteristic (ROC) area of 0.72. A cut-point of 3.3 could separate the patients in a larger group with a risk of approximately 26% to develop delirium and a smaller group having a risk of approximately 6%. CONCLUSION: The IQCODE is a useful tool to predict delirium among older inpatients, but it may not stand alone. It can be a useful supplement to other clinical information and observations in detecting patients needing dementia-friendly treatment and care.

Exercise gaming - a motivational approach for older adults with vestibular dysfunction.

Purpose The purpose of the study was to identify possible reasons for a modest level of exercise compliance during computer-assisted training for vestibular rehabilitation. Method Qualitative design and analysis of 14 semi-structured interviews with seven participants before and after a period with computer-assisted home training. The interviews evolved around themes, such as the elderly participants' self-efficacy, motivation and acceptance of the technology. Results Age was not an excuse for the modest exercise compliance. The participants were basically self-efficient and accepted the technology, but their knowledge and understanding of the training programme were insufficient. The participants asked for a greater variation in the exercises and asked for closer contact with the physiotherapist. When Mitii is used for vestibular rehabilitation, the system has some limitations. Conclusions The modest level of exercise compliance can be explained by (1) missing variety of exercise speed and duration and lack of introducing new exercises, (2) insufficient interaction with the physiotherapist regarding the participants' performance and lack of social contact with other patients and (3) desire for a deeper understanding of the training programme with supplying information on the parts of the vestibular system addressed by the training. Implications for Rehabilitation Computer-assisted technologies should generate feedback on the quality of user performance and inform the patient of the relevance of the exercise. The technology should support social contact among patients with the same diagnosis and establish contact with the physiotherapist at the hospital advice and feedback. Varity and adjustments to exercises are necessary to maintain motivation and exercise compliance.

Nutritional Follow-Up after Discharge Prevents Readmission to Hospital - A Randomized Clinical Trial.

OBJECTIVE: To compare the effects of two individualized nutritional follow-up intervention strategies (home visit or telephone consultation) with no follow-up, with regard to acute readmissions to hospital at two points in time, 30 and 90 days after discharge from hospital. DESIGN: Randomized clinical trial with two intervention groups and one control group, and monitoring on readmission at 30 and 90 days after discharge. SETTING: Intervention in the participants' homes after discharge from hospital. PARTICIPANTS: Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone. Exclusion: Nursing home residents and patients with terminal illnesses or cognitive impairment. Randomization: Upon discharge, the patients were stratified according to nutritional status (MNA), and assigned to one of three groups: 'home visit', 'telephone', or 'control' group. INTERVENTION: Individualized nutritional counselling of the patient and the patient's daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patient's homes, or over the telephone. All patients received a diet plan on discharge. The control group received standard care, but no follow-up after discharge. MEASUREMENTS: Information on readmissions to hospital and mortality at 30 and 90 days after discharge was obtained from electronic patient records. Intention-to-treat (ITT) and per-protocol (PP) analyses were carried out. RESULTS: Two-hundred and eight participants were randomized, 73 to home visits, 68 to the telephone consultation group, and 67 to the control group. The mean age of the participants was 86.1 years. Home visit participants had a lower risk of readmission to hospital compared to control participants at 30 days after discharge (HR=0.4; 95% CI: 0.2-0.9, p=0.03) and 90 days after discharge (HR=0.4; 95% CI: 0.2-0.8, p<0.01). No significant difference was detected between the telephone consultation group and the control group, at either 30 days (HR=0.6, 95% CI: 0.3-1.3, p=0.18) or 90 days after discharge (HR=0.7, 95% CI: 0.4-1.3, p=0.23). The PP analysis revealed that the risk of readmission was significantly lower in the home visit group compared to the control group and the telephone consultation group compared to the control group, and this was evident at 30 days as well as at 90 days after discharge. CONCLUSION: An individualized nutritional follow-up performed as home visits seems to reduce readmission to hospital 30 and 90 days after discharge. Intervention by telephone consultations may also prevent readmission, but only among participants who receive the full intervention.

Early Nutritional Follow-Up after Discharge Prevents Deterioration of ADL Functions in Malnourished, Independent, Geriatric Patients Who Live Alone - A Randomized Clinical Trial.

OBJECTIVES: To compare the effects of two nutritional follow-up interventions with regard to preventing short-term deterioration in ADL, and to compare their effects on physical function, emotional health, and health-related quality of life. DESIGN: Randomized clinical trial with two intervention groups and one control group, and a follow-up period of eight weeks. SETTING: Intervention in the participants' homes after discharge from hospital. PARTICIPANTS: Inclusion: Malnourished geriatric patients and patients at risk of malnutrition (MNA<24), aged 75 years and older, living at home and alone. Exclusion: Nursing home residents and patients with terminal illnesses or cognitive impairment. Randomization: At discharge, the patients were assigned to one of three groups: 'home visit', 'telephone consultation', or 'control' group. INTERVENTION: Individually tailored nutritional counselling of the patient and the patient's daily home carer by a clinical dietician one, two, and four weeks after discharge from hospital. The counselling was either in-person at the patients' homes, or by telephone. The control group received no follow-up after discharge. MEASUREMENTS: Primary outcome: Change in ADL (Barthel-100 score) at discharge and eight weeks later. SECONDARY OUTCOMES: Change in physical performance (handgrip strength, 30-sec. chair stand test, CAS), quality of life and depression measurements (SF-36, Depression List, Geriatric Depression Score), and Avlund mobility-tiredness score (Mob-T). RESULTS: Two-hundred and eight participants were randomized, 73 to home visits and 68 to telephone consultations. The control group comprised 67 patients. The mean age of the participants was 86.1 years. At eight weeks after discharge, 157 completed the follow-up (home visit 52, telephone consultation 51, and control group 54). The mean age of these patients was 85.8 years. More patients in the home visit group improved or maintained their ADL (96%), compared to the telephone (75%) and control groups (72%), p<0.01. No difference was detected among the groups with regard to physical measurements, health-related quality of life, and emotional health. CONCLUSION: Early nutritional follow-up after discharge, performed as home visits, prevents deterioration of ADL in malnourished, independent, geriatric patients who live alone and thereby preserves their independence.

Absence of 'over-the-counter' medicinal products in on-line prescription records: a risk factor of overlooking interactions in the elderly.

PURPOSE: To assess possible origins of harmful interactions in elderly patients arising from the current absence of information on over-the-counter (OTC) medicines in the Danish 'on-line prescription record'. METHODS: Information on current use of prescription drugs and OTC medicinal products (non-prescription drugs, herbal medicine, dietary supplements, and others) was collected by home visit interviews. The latter OTC products were not listed in an on-line prescription record that covered the previous two years. Information on interactions between OTC medicines and between OTC products and prescription drugs was obtained from the Danish National Drug Interaction Database. RESULTS: Of the 309 patients recruited (median age 75 years, interquartile range (IQR) 70-81), 229 (74%) used 568 OTC medicines not listed in the Danish 'on-line prescription record', amongst which we identified 166 potential interactions - between OTC treatments or between OTC and prescription drugs. Fifty percent of patients taking OTC medicines were exposed to potential interactions, i.e. one to three instances per patient. Twenty-five percent of patients exposed to interactions experienced interaction listed as 'Can be used with certain precautions'. CONCLUSION: The absence of information on OTC products in an on-line prescription record entails a risk of overlooking interactions in elderly patients. Such products should be included in on-line medication records to prevent adverse effects from interactions. However, online medication records are not available in all countries and as inclusion of data on OTC drugs seem not to be feasible presently. Still, it is highly recommended that the patient's drug list is reviewed on a regular basis.

Instantaneous detection of nonadherence: quality, strength, and weakness of an electronic prescription database.

BACKGROUND: The "personal electronic medicine profile" (PEM) is a Web-based tool for electronic prescription and monitoring of purchased medicine. It is based on the National Prescription Database and contains data on all prescriptions in Denmark. It includes information on time of drug purchase, number of tablets, and prescribed daily dosage. This allows calculation of the expected time for new purchases. PURPOSE: To study the accuracy of the PEM as a tool for monitoring drug nonadherence as compared with pill counts (PCs). METHODS: Five hundred eighty-three randomly selected elderly Danish citizens older than 65 years taking more than four drugs were studied. They were visited three times by a nurse who counted their medicine supply. Contingency table analysis was used to compare drug nonadherence calculated from PC with that revealed by PEM. For PC and PEM, an adherence level of at least 80% was defined as acceptable. RESULTS: PEM could not accurately process (non)adherence in 44% of all drugs. The probability of identifying drug nonadherence with PEM was low (negative predictive value 23%). Incomplete prescription information (34%) and inaccurate dosage registration (10%) were the major sources of error. CONCLUSION: PEM is inferior to PC for accurate monitoring of drug nonadherence. The inaccuracy is due to erroneous prescription information. PEM could be a powerful tool for electronic monitoring of drug nonadherence if prescription information was recorded uniformly and correctly. To increase the accuracy, we recommend informal free-text dosing instruction to be translated into a formal one by use of appropriate software such as library of phrases.

Improved nutritional status in elderly patients 6 months after stroke.

INTRODUCTION: Nutritional status among stroke patients has received limited attention despite the fact, that it may have an influence on clinical outcome. Previous studies have estimated that 15-20 % of patients suffer from malnutrition in the acute phase of stroke, but so far no studies have focused on the late rehabilitation phase after stroke in the patients own home, where the attention on nutrition may be reduced. AIMS: To determine the prevalence of malnutrition during 6 months of stroke rehabilitation, and to investigate the association between nutritional status, functional recovery, length of stay in hospital and infectious complications. SUBJECTS AND METHODS: 89 patients with ischemic stroke consecutively admitted to a geriatric stroke rehabilitation unit had their nutritional status evaluated in the hospital at 1 week and 5 weeks after stroke, and in their own home at 3 months and 6 months. Nutritional status was evaluated by body weight, body mass index (BMI), mid upper arm circumference (MAC), triceps skinfold thickness (TSF) and serum concentrations of albumin and transferrin. Malnutrition was defined if the patients had 2 or more abnormal nutritional variables. RESULTS: We found a significant increase in albumin from 1 week to 6 months (P < 0.0001), and a significant increase in transferrin form 5 weeks to 6 months (P < 0.05). There was no significant change in weight or BMI from 1 week to 6 months. The number of patients with 2 or more abnormal nutritional variables was 31 (35 %) at 1 week and was reduced to 20 (22 %) at 6 months. CONCLUSION: 35 % of elderly patients with ischemic stroke admitted to a geriatric rehabilitation unit were malnourished 1 week after stroke. Particularly serum proteins and body fat were affected. Follow-up of nutritional variables showed improvement for serum proteins, and 22 % of the patients were malnourished 6 months after stroke.

Insulin resistance is accompanied by increased von Willebrand factor levels in nondiabetic women: a study of offspring of type 2 diabetic subjects compared to offspring of nondiabetic subjects.

OBJECTIVES: To examine whether levels of von Willebrand factor (vWF), fibrinogen and fibronectin are related to a parental history of type 2 diabetes and to determine possible explanatory factors for high versus low vWF and fibrinogen. DESIGN: Cross-sectional study. SUBJECTS, MAIN OUTCOME MEASURES: We compared vWF, fibrinogen and fibronectin in 88 nondiabetic offspring of type 2 diabetic subjects (relatives) and 103 offspring of nondiabetic subjects (controls). Other measurements included urinary albumin excretion rate, blood pressure, lipid profile and insulin resistance using homeostasis model assessment (HOMAIR). RESULTS: There were no significant differences in vWF (1.12 vs. 1.06 IU x mL(-1), P = 0.296), fibrinogen (3.2 vs. 3.1 g x L(-1); P = 0.263) or fibronectin (0.39 vs. 0.40 g x L(-1), P = 0.448) between relatives and controls. With multiple logistic regression we determined explanatory factors for high versus low vWF and fibrinogen. Age (P < 0.01), urinary albumin excretion rate (P < 0.05), ischaemic heart disease (IHD) (P < 0.05) were found to be significant explanatory factors for vWF above the median (1.10 IU x mL(-1)). Interaction between insulin resistance and sex was found. Odds ratio for high versus low insulin resistance was 18.39 (P < 0.001) for women and 1.92 (P = 0.32) for men. Body mass index (BMI) (P < 0.05), sex (P < 0.01), smoking status (P < 0.05) and IHD (P < 0.01) were significant explanatory factors for fibrinogen above the median (3.1 g x L(-1)). CONCLUSIONS: Levels of vWF, fibrinogen and fibronectin were not influenced by a parental history of type 2 diabetes. Insulin resistance was found to be a significant risk indicator for high vWF only in women. This may indicate that insulin resistance is a higher risk factor for women than for men, when the outcome is endothelial dysfunction possibly resulting in overt cardiovascular disease.

Drug therapy in the elderly: what doctors believe and patients actually do.

AIMS: To examine the medication adherence among old persons living in their own homes, to assess their knowledge of their medication, and to indicate target areas for intervention. METHODS: A cross-sectional study of data collected from randomly selected samples of 348 persons, aged 75 years recruited from a population-based register in the municipality of Aarhus, Denmark. Information on all drugs was collected from the subjects during a home visit, and their drug storage was examined. Information was collected from the general practitioners (GP). The measures of adherence were scores of agreements between the GPs' lists and the subjects' actual drug consumption. RESULTS: We found disagreement between the drug information collected from the study population and from the GPs: concerning drugs in 22% of the study-population, concerning doses in 71%, and concerning regimens prescribed by the GP in 66%. Twenty-four percent stated that they did not always follow prescriptions. Most of the deviations from prescriptions were toward lower doses and less frequent drug intake. The drugs most often involved in deviations were hypnotics, analgesics, bronchodilators and diuretics. Sixty percent of the participants knew the purpose of medication, and 21% knew the consequences of omission of the drugs. Less than 6% of the subjects knew about the toxic risks, side-effects, or potential drug interactions. The participants' knowledge of the drugs was positively associated with their adherence. We found a correlation between an increased number of prescribed frequency of drug intake per day and deviation from the regimen (r = 0.25, P = 0.01). There was a positive association between nonadherence and the use of three or more drugs (odds ratio (OR) 2.5; 95% confidence interval (CI) 1.5,4.1), prescriptions from more than one doctor (OR 2.5; 95% CI 1.3,4.8), and probability of dementia (OR 9.0; 95% CI 1.1,72.5). Moreover compliance aids facilitated adherence (OR 4.4; 95% CI 1.6,12.3). Persons living alone were more prone to medication errors (OR 2.0; 95% CI 1.1,3.5). CONCLUSIONS: A differentiated evaluation of adherence by considering the drug, the dose, and the regimen separately produced quantifiable data concerning the subjects' medication habits. Non-adherence ranged from 20 to 70% depending on the measuring method. The participants' knowledge of the treatment was poor. Our results suggest that better information on medication and the use of compliance aids may prevent nonadherence. Special attention should be paid to persons receiving three or more drugs, living alone, receiving drugs from other doctors, and to persons with predementia symptoms, as they are at higher risk of nonadherence.

Autonomic neuropathy in nondiabetic offspring of type 2 diabetic subjects is associated with urinary albumin excretion rate and 24-h ambulatory blood pressure: the Fredericia Study.

The aim of this study was to examine the impact of parental type 2 diabetes on the autonomic nervous system and to determine whether autonomic neuropathy is present and associated with changes in 24-h ambulatory blood pressure (AMBP) and urinary albumin excretion rate (UAER) in nondiabetic subjects with parental type 2 diabetes. We examined 223 nondiabetic offspring of type 2 diabetic subjects and a control group of 258 offspring of nondiabetic subjects. The autonomic nervous system was assessed by three cardiovascular reflex tests, 24-h AMBP was measured with an oscillometric recorder (90207; Spacelabs, Redmond, WA), and UAER was determined through three overnight urine samples. The subjects with parental type 2 diabetes had significantly lower heart rate variation in all three bedside tests (P < 0.01) than subjects without parental diabetes. The prevalence of autonomic neuropathy in the nondiabetic offspring with parental type 2 diabetes (6.7%) was significantly (P < 0.01) higher compared with the control group (1.6%). Autonomic neuropathy was associated with a higher fasting insulin level (P < 0.05), higher UAER (P < 0.001), higher 24-h mean AMBP (P < 0.01), and reduced diurnal blood pressure variation (P < 0.001) after adjustment for age, sex, and BMI. In conclusion, parental type 2 diabetes was found to be associated with alterations in the autonomic nervous system in nondiabetic subjects. The presence of autonomic neuropathy in subjects with parental type 2 diabetes was associated with higher UAER, fasting insulin level, and 24-h AMBP and a reduced diurnal blood pressure variation. This study indicates that parental type 2 diabetes has an impact on the cardiac autonomic function in nondiabetic subjects.

The consumption of drugs by 75-year-old individuals living in their own homes.

OBJECTIVE: To examine the drug consumption and the extent of polypharmacy (defined as daily intake of three or more drugs) among 75-year-old persons living in their own homes and to point out potential problems associated with it. METHODS: Information on the intake of all drugs was collected from 492 subjects randomly selected. The subjects were interviewed at home, and their drug storage was examined. Information was also collected from the general practitioners (GPs) and from prescription databases. Database information comprised prescribed drugs used by the study population and the background population. RESULTS: Eighty-seven percent of the study population received prescribed drugs and 72% used over-the-counter (OTC) drugs. Only 3% of the subjects did not take any drugs. Eighty percent of females and 60% of males used central nervous system (CNS) drugs, the most commonly used category. The subjects took on average 4.2 different prescribed drugs and 2.5 OTC drugs. Sixty percent used three or more prescribed drugs and 34% used five or more. Thirty percent used three or more OTC drugs. Seventeen percent had prescribed drugs not in use at the time of the examination in their drug storage. Twenty-five percent of the prescribed drugs were used without the GPs' knowledge. Thirty-one percent of the study population received prescribed drugs from two or more physicians. Potential drug interactions with clinical significance were found among 15.3% of the participants and were positively correlated to polypharmacy. CONCLUSION: Almost all 75-year-old persons receive drugs. The observed polypharmacy may increase drug-related risks. The discrepancies between the GPs' knowledge of their patients' medication and the actual intake may involve a potential risk. A better registration of the patients' total medication and the implementation of a common medication database for the use of all involved physicians may improve medication and reduce risks.

Normal blood pressure and preserved diurnal variation in offspring of type 2 diabetic patients characterized by features of the metabolic syndrome: the Fredericia Study.

OBJECTIVE: To examine whether an elevated blood pressure (BP) level and an impaired reduction in nocturnal BP are already present in nondiabetic first-degree relatives of type 2 diabetic patients. RESEARCH DESIGN AND METHODS: We examined 253 offspring of type 2 diabetic patients using ambulatory BP monitoring and compared the BP level and profile with 275 offspring of nondiabetic subjects. Anthropometric measures and cholesterol, fasting blood glucose, and insulin levels were also compared between groups. RESULTS: No significant differences in BP level (P > 0.05) or diurnal BP profile were evident between the nondiabetic glucose-tolerant offspring of type 2 diabetic subjects and the offspring of nondiabetic subjects. BMI (P < 0.05 and P < 0.01, male vs. female), waist-to-hip ratio (P < 0.05), fasting blood glucose (P < 0.01), C-peptide (P < 0.05 and P < 0.01, male vs. female), insulin resistance index (P < 0.05 and P < 0.01, male vs. female), triglycerides (P < 0.05), apolipoprotein B (apoB) (P < 0.01 and P < 0.05, male vs. female), and apoA1/apoB (P < 0.01) were significantly higher in the nondiabetic offspring of type 2 diabetic subjects than in the offspring of nondiabetic subjects. CONCLUSIONS: This study shows a preserved diurnal BP profile and a normal BP level in the nondiabetic glucose-tolerant offspring of type 2 diabetic subjects compared with the offspring of nondiabetic subjects, although the offspring of diabetic patients are characterized by features of the metabolic syndrome.

Cardiovascular autonomic neuropathy in insulin-dependent diabetes mellitus: prevalence and estimated risk of coronary heart disease in the general population.

OBJECTIVES: The aim of the study was to estimate the prevalence of cardiovascular autonomic neuropathy (CAN) in Type 1 diabetes mellitus in the general population and to assess the relationship between CAN and risk of future coronary heart disease (CHD). METHODS: The Type 1 diabetes mellitus population in the municipality of Horsens, Denmark, was delineated by the prescription method and a random sample of 120 diabetics aged 40-75 years was recruited. Type 1 diabetes mellitus was registered if fasting C-peptide was below 0.30 nmol L(-1). The E/I ratio was calculated as the mean of the longest R-R interval in expiration divided by the shortest in inspiration during deep breathing at 6 breaths min(-1) and taken to express the degree of CAN. A maximal symptom-limited exercise test was carried out and the VA Prognostic Score, indicating risk of cardiovascular death or non-fatal myocardial infarction, was computed. Additionally, the 10-year risk of CHD was calculated using the Framingham model. RESULTS: A total of 84 people responded, of whom 71 had Type 1 diabetes mellitus. The E/I ratio was measured in 69 people. The prevalence of CAN expressed as an E/I ratio below the normal 5th percentile was 38%. The E/I ratio was significantly reduced in old age, long duration of diabetes, female gender, high fasting blood glucose, triglyceride, systolic blood pressure and urinary albumin excretion. A high risk of future CHD calculated using the Framingham model was associated with a low E/I ratio (r = -0.39, P = 0.001). Exercise capacity, rise in systolic blood pressure and heart rate were positively correlated with the E/I ratio. A high VA Prognostic Score was correlated with a low E/I ratio (r = - 0.58, P < 0.0005). The risks estimated by the two models were significantly correlated (r = 0.60, P < 0.0005). CONCLUSION: The prevalence of CAN in the 40-75-year-old Type 1 diabetes mellitus population is estimated to be 38%. CAN is associated with exercise test parameters and a coronary risk factor profile indicating a high risk of future CHD.

Increased QT dispersion in patients with insulin-dependent diabetes mellitus.

AIM: To compare the QT dispersion in unselected patients with insulin-dependent diabetes mellitus to non-diabetic control subjects and to assess the association between the QT dispersion and cardiac autonomic neuropathy, ischaemic heart disease, blood pressure level and nephropathy. METHODS: 42 patients with insulin-dependent diabetes mellitus and 80 control subjects aged 40-57 years participated. The QT interval was measured in a resting 12-lead electrocardiogram (ECG) and the QT dispersion defined as the difference between the maximum and minimum QT interval. Bazett's formula was used to correct for heart rate (QTc). The degree of cardiac autonomic neuropathy was assessed by five function tests and ischaemic heart disease was defined by a previous myocardial infarction, ECG abnormalities or a positive exercise test. RESULTS: Compared to control subjects, diabetic patients had a longer QTc interval (433 vs. 416 ms; P=0.002) and a higher QT dispersion (36 vs. 30 ms; P=0.02). In the diabetic group, the QTc interval was prolonged in patients with autonomic neuropathy (449 vs. 420 ms; P=0.007) and the QT dispersion was increased in patients with ischaemic heart disease (51 vs. 33 ms; P=0.004). No association was found to urinary albumin excretion rate or blood pressure. CONCLUSION: The QT dispersion as well as the QTc interval is increased in patients with insulin-dependent diabetes mellitus. The association between QT dispersion and ischaemic heart disease indicates that abnormalities in cardiac repolarisation may be caused by complications to diabetes rather than diabetes in itself.

The diurnal variation in blood pressure should be calculated from individually defined day and night times.

The aim of this study was to compare the nocturnal fall in BP parameters calculated from individually defined periods of day and night to values computed from collectively fixed day/night definitions. Day and night periods were defined according to 3 different methods: (i) the individually defined time of getting up and going to bed obtained from participant diaries (MethodIND); (ii) the mean time of rising and retiring in the group (MethodMEAN); and (iii) a daytime period from 07.00-22.00 h as recommended by The Scientific Committee (Method722). The ambulatory BP was recorded every 30 min over 24 h. One hundred and eighty-seven persons aged 40-66 years participated. With MethodIND, the BP load, systolic, diastolic and mean BPs were higher in the daytime and lower in the night-time compared to the results using Method722 and MethodMEAN. The nocturnal BP fall using MethodIND was larger than the fall calculated from every possible fixed division in the period from 3 h before till 3 h after the group mean time of getting up and going to bed (p < 0.001). The lowest frequency of non-dipping, defined as a nightly fall in systolic and diastolic BP below 10%, was observed using MethodIND (10%). Compared to MethodIND, 11% were misclassified as non-dippers by Method722 and 8% by MethodMEAN. We conclude that the diurnal blood pressure variation based on individually defined periods of day and night is larger than the variation based on any collectively fixed day/night definition. It is recommended that assessment of the nocturnal change in BP be based on individually defined periods of day and night.

Prevalence and prediction of silent ischaemia in diabetes mellitus: a population-based study.

OBJECTIVES: The aim of the study was to estimate the prevalence of silent ischaemia in diabetic subjects in the population, to compare the prevalence of silent ischaemia in diabetics and non-diabetics and to attempt to predict the presence of silent ischaemia in diabetic subjects. METHODS: A random sample of 120 users of insulin and 120 users of oral hypoglycaemic agents aged 40-75 years living in the Danish municipality of Horsens were asked to participate in the study. Corresponding to the youngest half of the sample two non-diabetic controls were randomly selected from the Central Population Register. ST-depression of horizontal or descending character of at least 0.1 mV measured 80 ms after the J-point on either exercise ECG or Holter ECG was considered indicative of myocardial ischaemia. Angina pectoris was considered present if the Rose questionnaire was positive, or chest pain was registered simultaneously with ECG evidence of ischaemia. Individuals with ischaemia, but without angina pectoris, were defined as persons with silent ischaemia. RESULTS: Seventy-four percent of the invited group were included. The observed prevalence of silent ischaemia in diabetics was 13.5% (95% CI = 8.5-19.8%). No association was found between silent ischaemia and gender (P = 0.83) or diabetes type (P = 0.67). In the group of diabetics who had controls, the prevalence was 11.4%, and among the controls the prevalence was 6.4% (OR = 1.87, one-sided P = 0.079). Systolic blood pressure was highly predictive of silent ischaemia in the diabetic subjects (P = 0.005). No predictive value could be shown for other variables. CONCLUSION: This is the first population-based study of silent ischaemia in diabetes. The prevalence of silent ischaemia in diabetic subjects was 13.5%. The frequency of silent ischaemia did not differ significantly between diabetics and non-diabetics. Systolic blood pressure was predictive of silent ischaemia in diabetes.

Over-mortality as related to age and gender in patients with established non-insulin-dependent diabetes mellitus.

In 1981-1982, 5699 persons representing 92.9% of the total population aged 60-74 years living in Fredericia, Denmark, were interviewed about a possible history of diabetes and had a fasting blood glucose measured. A total of 236 gave a positive history of diabetes; 88 had one fasting blood glucose of 7 mmol/L or more. For each of these probands, an age- and gender-matched control person with normal fasting blood glucose and no history of diabetes was selected randomly. Of the 236, 91.5% had NIDDM as judged by glucagon-stimulated C-peptide tests. At the end of December 1995, the participants were traced through the National Register and their status (alive or dead) was determined. The date of death was confirmed. The median observation time from screening and inclusion in the study till death or the end of the observation period in December 1995 was 12.81 years, the maximum was 14.91, and the 25th and 75th percentile values were 6.36 and 13.94 years, respectively. At the end of 1995, 165 (74.4%) of 228 persons with known diabetes at the time of ascertainment had died opposed to 90 (40.4%) of the 223 nondiabetic control persons. The difference is statistically highly significant (p < 0.00001, log-rank test). Within the first 5 years of observation, 42.9% of diabetic men died and only 22.5% of non-diabetic men. This percentage of deaths in diabetic men was found already in the 60-64 year age interval (46.2%). The mortality rate for the non-diabetic population seems to increase later. After 13 years of observation, 74 (81.3%) of 91 men with known diabetes had died, in the age-matched control men, 50 (56.2%) of 89 (p = 0.00006). Ninety-one (66.4%) of 137 diabetic women had died: 40 (29.9%) of 134 control women (p < 0.00001). The difference between mortality in diabetic men and women, and between nondiabetic men and women is highly significant (p = 0.00285 and 0.00001, respectively). The over-mortality of established diabetic persons decreases with age. In the age group 60-74 years, the over-mortality is about 2.5 without gender difference.

Birth weight and cardiovascular risk factors in an epidemiological study.

Low birth weight has been proposed as a risk factor for development of non-insulin-dependent diabetes mellitus, hypertension, and cardiovascular disease in the adult. To ascertain the extent to which birth weight was associated with cardiovascular risk factors, we examined 620 subjects (median age 48 years) in a cross-sectional study. Of these 317 were offspring of diabetic patients and 303 were offspring of non-diabetic control subjects. Known risk factors for development of cardiovascular disease were correlated to birth weight and examined as dependent variables by multiple linear regression. Age, body mass index (BMI), subjects gender along with parental gender, diabetes status of the parents, and birth weight were independent variables. The variance of the risk factors as dependent variables explained by age, gender, and BMI as independent variables was examined and birth weight was added as an independent variable. We found birth weight was inconsistently correlated to the different risk factors in the different groups of subjects. When adjusted for age, BMI, subject's gender, parental gender, and the diabetes status of the parents, birth weight was negatively correlated to fasting blood glucose. In offspring of diabetic patients the explained variance of risk factors did not change as we added birth weight to the model. In offspring of non-diabetic subjects we found that the explained variance of diastolic blood pressure, fasting blood glucose, HbA1c, and cholesterol increased 1-3% as birth weight was added to the model. We conclude that birth weight may not be a major risk factor for development of hypertension and cardiovascular disease in our population.

Clinical features in persons with a family history of diabetes compared to controls (The Second Generation Fredericia Study).

OBJECTIVE: To compare clinical and biochemical features in non-diabetic persons with a family history of non-insulin dependent diabetes mellitus (NIDDM) to non-diabetic persons without a family history of diabetes. DESIGN: Cross-sectional study. SETTING: Population-based survey in Fredericia, Denmark. SUBJECTS: Seven hundred and forty subjects, the second generation of an earlier defined cohort was examined. The median age was 48 (range 26-65) years. Of the 740 subjects 696 were non-diabetic. INTERVENTIONS: The subjects had a clinical examination. MAIN OUTCOME MEASURES: Known risk factors for development of diabetes and cardiovascular disease. RESULTS: More offspring of diabetic persons had NIDDM (chi 2 = 6.36, P < 0.05). Non-diabetic males with a family history of diabetes had a higher BMI fasting blood glucose, and triglycerides compared to males without a family history of diabetes. Non-diabetic females with a family history of diabetes had a higher BMI, fasting blood glucose. HbA1C, diastolic blood pressure, and lower HDL-cholesterol than female offspring of non-diabetics. In a multiple regression model we found that non-diabetic off-spring of diabetic persons had higher fasting blood glucose and HbA1C compared to offspring of non-diabetic persons when adjusted for the independent variables age, BMI, WHR, and sex. CONCLUSION: Our results may indicate that the only inherited factors from NIDDM patients are plasma blood glucose. HbA1C and increased BMI which may be an indication for later diabetes, whereas other cardiovascular risk factors may be inherited independently of diabetes but associated with BMI.

Urinary albumin excretion in a population based cohort.

In order to compare a 1-h daytime urine specimen collection with a timed overnight collection, as well as different ways of expressing urinary albumin excretion: (urinary albumin excretion rate (UAE), urinary albumin concentration (UAC), and urinary albumin creatinine ratio (UACR)), a population of 922 people of whom 35 had diabetes was examined. The median age was 47 (range 26-65) years. The results of the different ways of collecting urine specimens and the different expressions of urinary albumin excretion were related to known cardiovascular risk factors. The daytime collection showed higher values of urinary albumin excretion than the overnight collections. Systolic blood pressure was an important risk factor correlated to UAE and UACR in the day as well as the overnight collection, followed by HbA1C in the total group and by BMI in the non-diabetic group. UAC showed significant relation to triglycerides and HDL-cholesterol. In conclusion, urinary albumin in a 1-h daytime collection showed a similar correlation to cardiovascular risk factors as the excretion of albumin in overnight collected urine. Follow-up studies are needed to compare day collections of urine as predictors of cardiovascular disease and early death with overnight collections.