Use of antihypertensive drugs and trends in blood pressure in the elderly.

BACKGROUND: During the 1980s data became available from randomized trials concerning the clear benefits of treating hypertension in the elderly. In three large communities, we examined the impact of these findings on rates of treatment, use of specific antihypertensive drugs, and rates of elevated blood pressure as well as distributions of levels. METHODS: In 1981 the National Institute on Aging initiated population-based cohort studies in the residents of three communities who were 65 years and older. East Boston, Mass; Washington and Iowa counties, Iowa; and New Haven, Conn. Participation rates ranged from 80% to 85% across sites with 10,294 community-dwelling participants in the combined cohorts. Baseline evaluation included inhome blood pressure assessment and medication inventory. Repeated in-home evaluations occurred 3 and 6 years after baseline and follow-up rates ranged from 71% to 88%. RESULTS: Use of antihypertensive drugs increased over time in all three communities: the age- and sex-adjusted rates of use were between 14% and 32% higher in 1988 and 1989 relative to 1982 and 1983. Parallel declines in the use of thiazide diuretics occurred in all three populations along with large increases in the use of angiotensin-converting enzyme inhibitors and calcium channel blockers. In East Boston and New Haven mean systolic blood pressure decreased substantially over time and the prevalence of elevated systolic pressure (> or = 160 mmHg) decreased overall as well as by age and sex. In Iowa the mean levels of systolic blood pressure were lowest at baseline and increased slightly. CONCLUSIONS: The reported evidence about the benefits of treatment for hypertension in the elderly was followed by substantial increases in treatment rates. The use of drugs with proven efficacy declined while the use of newer agents with theoretical advantages, not yet tested in clinical trials of mortality, increased. In the United States, the ongoing therapeutic efforts to lower elevated blood pressure in elderly populations may be contributing to the continuing decline in cardiovascular and stroke mortality.

Urinary free cortisol and separation anxiety early in the course of bereavement and threatened loss.

Among 56 persons who were acutely bereaved or threatened with a loss, a group with worsening separation anxiety over a period of a month early after the event had higher urinary free cortisol output than a group experiencing improvement in grief. Although not tested in this study, both these psychological and physiological measures may have potential for serving as early predictors of poor outcome in bereavement for the 15%-20% of exposed persons who are at risk for unresolved grief or persistent depressive syndromes.

Correlates of headache in a population-based cohort of elderly.

Data from a community-based study of 3811 persons aged 65 years and older were used to describe the characteristics of headache in the elderly. Subjects were asked whether they experienced headache in the past year, the frequency and severity of their headaches, and whether they experienced three symptoms of migraine: unilaterality, nausea or vomiting, an aura preceding the headache. Prevalence of headache in those aged more than 65 years declined with age in both men and women; women had a higher prevalence in each age group. The same was true for frequent, severe, and migrainous headache. We examined age- and sex-adjusted correlations of headache with several medical and social factors. Prevalence of any headache was strongly associated with joint pain, depression, bereavement, waking during the night, use of eyeglasses, symptoms of temporomandibular joint dysfunction, and self-assessment of health. Similar variables were associated with frequency, severity, and migrainous symptoms, and thus could not be distinguished among these various types.

Frequency of long-term lower limb ischemia associated with intraaortic balloon pump use.

Lower limb ischemia is a frequent complication of intraaortic balloon pump (IABP) use. The incidence and risk factors for acute ischemia have been well-defined, but little is known about long-term ischemic complications. This prospective study evaluated the incidence, nature, progression and predisposing factors for long-term lower limb ischemia in 151 patients who were previously treated with the IABP. These persons were interviewed and their lower extremities examined 12 to 20 months after undergoing IABP counterpulsation. Limb ischemia, characterized primarily by ipsilateral discomfort and diminished pulses, occurred in 18% of those evaluated. Evidence of ischemia worsened over time in 14%. Logistic regression analysis, which was based on variables found to be significant in bivariate analysis, revealed that the occurrence of limb ischemia acutely, cardiogenic shock as an indication for IABP insertion, and smoking (at the time of hospitalization or having quit < 10 years previously) were risk factors for long-term lower limb ischemia. The adjusted odds ratio for acute limb ischemia was 8.89 (95% confidence interval 2.80 to 28.21), for cardiogenic shock 3.59 (95% confidence interval 1.01 to 12.75), and for smoking 2.87 (95% confidence interval 1.10 to 7.46). Increasing numbers of patients are undergoing IABP counterpulsation and a greater proportion of these are surviving their acute event and resuming active lives. It is essential to recognize that detrimental consequences of this device can persist long after hospitalization.

Malnutrition and subsequent ischemic heart disease in former prisoners of war of World War II and the Korean conflict.

The harsh treatment of former prisoners of war (POWs) of World War II and the Korean conflict resulted in severe malnutrition. Although rarely linked to specific long-term medical problems, a specific marker of malnutrition, self-reported lower limb edema (presumably due to a vitamin B deficiency) was associated with a three-fold increase in subsequent death attributed to ischemic heart disease (IHD) during the follow-up period from 1967 through 1975. Although there is at present no medical basis for linking edema, which is perhaps a marker for some unmeasured risk factor, to subsequent IHD, this finding may nonetheless have medical implications for the group of former POWs and other populations with severe dietary deficiency. It also suggests there may be a need to reexamine currently held theories on malnutrition and subsequent chronic disease.

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.

Analysis of data from successive complex sample surveys, with an example of hypertension prevalence from the United States Health Examination Survey.

There are a number of ongoing large complex sample surveys focused on health data being undertaken at present. Because of time and cost constraints, these surveys are usually highly stratified multistage cluster samples. The complexity of this design has made the usual simple random sampling assumptions untenable and therefore analyses are rarely more than descriptive in nature with some pairwise comparison using t-tests. Generalized regression procedures using weighted least squares are now available for solving this difficulty by incorporating the sample design into the data analysis through the variances and covariances of the sample estimates. These procedures are extended to the analysis of data from complex surveys conducted at two or more different points in time (successive surveys). The method is illustrated with an example taken from published data of hypertension prevalence estimates from the Health Examination Survey-Cycle I (1960-1962) and the Health and Nutrition Examination Survey (1971-1975).

Association of visual impairment with mobility and physical function.

OBJECTIVE: To examine the association of distant vision and physical function in the population of older adults. DESIGN: Cross-sectional and cohort study. PARTICIPANTS: 5143 older residents of three communities (Established Populations for the Epidemiologic Studies of the Elderly) who were interviewed in 1988-89, including residents of two communities who were re-interviewed 15 months later (n = 3133, 97% of those eligible). MEASURES: Visual acuity screening, self-reported activities of daily living and mobility, and objective physical performance measures of balance, walking, and rising from a chair. RESULTS: Limitations in mobility, activities of daily living, and physical performance were associated with worse visual function. In prospective analyses controlling for potential confounders, participants with severe visual impairment had 3-fold higher odds of incident mobility and activity of daily living limitations than those with acuity of 20/40 or better (P < 0.001). In prospective analyses investigating the relationship of vision with improvement in function, those with poor vision were about half as likely to improve as those with better acuity, but this relationship was only statistically significant for improvement in mobility limitations. CONCLUSIONS: Distant visual function appears to play an important role in physical function, particularly for mobility. An intervention to improve vision in at-risk elders might preserve function and prevent disability; this warrants further investigation.

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.

Intermittent claudication and subsequent cardiovascular disease in the elderly.

BACKGROUND: This study reports the prevalence of intermittent claudication (IC) in ambulatory community-resident adults age 65 years or older, compares cardiovascular risk factors and comorbidity of persons with and without IC, and examines the independent association of IC in predicting all cause and cardiovascular mortality, myocardial infarction, stroke, and disability. METHODS: Data are from a pooled sample of 8996 older adults from the East Boston, New Haven, and Iowa sites of the Established Populations for Epidemiologic Studies of the Elderly, conducted between 1982 and 1988. RESULTS: 2.4% and 1.5% of men and women, respectively, reported IC. Persons with IC had significantly higher rates of diabetes and cardiovascular comorbidity than persons without IC, and they were more likely to smoke. Claudication predicted higher rates of mortality, myocardial infarction, stroke, and disability independent of associated cardiovascular conditions and risk factors. Among persons with a history of angina, myocardial infarction, and/or stroke, those who reported IC had a twofold greater risk of cardiovascular mortality. CONCLUSION: The study demonstrated that IC is an important predictor of mortality and cardiovascular morbidity in ambulatory older adults independent of associated coronary ischemia and cardiovascular disease risk factors. Results suggest that inclusion of a measure of IC improves the prediction of cardiovascular morbidity and mortality in older adults.

Effects of sex on differences in awareness, treatment, and control of high blood pressure.

Our purpose was to explain the reasons for sex differentials in the awareness, treatment, and control of hypertension by identifying major social and behavioral predictors of these three sequential stages of high blood pressure control. We analyzed data on all 1,433 hypertensive subjects from the First Connecticut Blood Pressure Survey. Hypertensive women were more likely than hypertensive men to be aware of their high blood pressure (odds ratio = 1.40; confidence interval = 1.10-1.79) and to have controlled levels of blood pressure (odds ratio = 1.62; confidence interval = 1.08-2.44). Men and women who were aware of their hypertension were equally likely to be treated. Sex still explained differences in awareness and control of hypertension after adjusting for other significant variables. We conclude that sex is an important predictive covariate for adjustment in explaining differences in awareness and control of high blood pressure. Health care professionals should be aware of the differential role of sex when informing and treating hypertensive patients.

Spouse similarities in high blood pressure knowledge: implications for control of high blood pressure.

This study describes the general knowledge about high blood pressure of husbands and wives using data from all 1,260 white spouse pairs from the 1982 Connecticut Blood Pressure Survey and examines the relationship between high blood pressure knowledge and control of hypertension. We found the average level of knowledge to be high; about 70% of the items were answered correctly. The correlation between spouses' knowledge about high blood pressure was significantly high (r = .41). Multiple regression analysis was used to control for other variables that might influence the spousal correlation in knowledge. When controlling for education, age, socioeconomic status, and hypertension status of both spouses, the correlation between spouses' knowledge remained significant (r = .24). Respondents' knowledge and spouses' knowledge about high blood pressure were significantly related to high blood pressure control among hypertensive persons, particularly to being aware of hypertension and being in current treatment.

Depressive symptoms in the elderly: association with total white blood cell count.

1. The white blood cell (WBC) count in those with high depressive symptoms and non-depressed participants in the Established Populations for Epidemiologic Studies of the Elderly (EPESE) were compared. 2. Of 3769 participants 10.8% had high depressive symptoms as assessed by the Centers for Epidemiologic Studies Depression (CES-D) Scale. The mean white blood cell count was higher in the high depressive symptoms group compared to the non-depressed group (6.8 +/- 0.12 x 10(9) WBC/1 and 6.5 +/- 0.03 x 10(9) WBC/1, respectively, p < 0.01). 3. Because older adults frequently have disabling chronic conditions which could both influence their leukocyte count and cause depressive symptoms, models were developed which controlled for the potential confounding. Even after adjusting for potential confounders, high depressive symptoms were still associated with higher white blood cell counts.

An epidemiologic study of lifting and twisting on the job and risk for acute prolapsed lumbar intervertebral disc.

An epidemiologic case-control study undertaken in Connecticut during 1979-1981 indicated that persons with jobs requiring lifting objects of more than 11.3 kg (25 lb) an average of more than 25 times per day had over three times the risk for acute prolapsed lumbar intervertebral disc as people whose jobs did not involve lifting objects of this weight. If the body was usually twisted while the lifting was done, this elevation in risk was apparent with less frequent lifting. An especially high risk for prolapsed lumbar disc was associated with jobs involving lifting objects of more than 11.3 kg with the body usually twisted and the knees not bent while the lifting was done. Neither lifting objects of less than 11.3 kg nor twisting without lifting was associated with an increase in risk.

A survey for assessing physical activity among older adults.

In 1988, the Yale Physical Activity Survey (YPAS) was designed and then administered to healthy older populations of volunteers (aged 60-86) to establish its 2-wk repeatability and relative validity. Among the 76 volunteers in the repeatability substudy, correlation coefficients between the two administrations of the survey for the eight YPAS summary indices ranged from 0.42 (P = 0.0002) to 0.65 (P = 0.0001). Among the 25 subjects in the validation substudy, weekly energy expenditure (r = -0.47; P = 0.01) and daily hours spent sitting (r = 0.53; P = 0.01) correlated with resting diastolic blood pressure, while the YPAS activity dimensions summary index (composed of questions on vigorous activity, leisurely walking, moving, sitting, and standing) correlated positively with estimated VO2max (r = 0.58; P = 0.004) and inversely with percent body fat (r = -0.43; P = 0.03). The YPAS index of vigorous activity also correlated positively with estimated VO2max (r = 0.60; P = 0.003) and the moving index correlated marginally with body mass index (r = -0.37; P = 0.06). We conclude that the YPAS demonstrates adequate repeatability, and some validity by correlating with several physiologic variables reflecting habitual physical activity. The value of the YPAS, however, in accurately assessing low intensity activity remains to be established.

An epidemiological study of acute prolapsed cervical intervertebral disc.

In this epidemiological study of acute prolapsed cervical intervertebral disc, we found that people in the fourth decade of life were affected somewhat more frequently than individuals in other age groups, and men with a prolapsed cervical disc outnumbered women by a ratio of 1.4 to one. Factors that were associated relatively strongly with this diagnosis were frequent lifting of heavy objects on the job that was held around the time of the onset of symptoms, cigarette-smoking, and frequent diving from a board. Positive associations that were of borderline statistical significance or were not statistically significant were found with operating or driving vibrating equipment and time spent in motor vehicles. Variables that did not appear to affect the risk for a prolapsed cervical disc included participation in certain sports other than diving, frequent wearing of shoes with high heels, the number of pregnancies or live births, frequent twisting of the neck on the job, time spent sitting on the job, and smoking cigars or a pipe.

Sex differences in prolactin change during mourning.

Fourteen men and 12 women were interviewed eight weeks after conjugal bereavement to discuss the events prior to the spouse's death and the subsequent bereavement period. Prolactin (PRL) was measured at the beginning and end of the interview. Descriptions of the deceased spouse were obtained during the interview and rated for Developmental Level of Object Representation (DLOR), a measure of the cognitive complexity of the description. There were significant correlations between DLOR and PRL change for both men and women but the correlation for women was positive and the correlation for men was negative. These findings extend the literature on the psychological correlates of PRL change and suggest that the physiological changes associated with mourning are different for men and women.

Bereavement and catecholamines.

Urinary catecholamine output was studied in 59 middle-aged and elderly persons who were either acutely bereaved (n = 39) or threatened with the loss of a spouse (n = 20). The study was done with the hypothesis that urinary catecholamine output would be elevated among the bereaved subjects both in comparison to norms in the literature for non-stressed controls and to the group of subjects who were threatened with a loss. It was also expected that individually high measures of psychological distress would be associated with high urinary catecholamines. Twenty-four hour urinary output of norepinephrine and epinephrine was observed to be higher than normal during acute bereavement but was not associated with depression scores. No differences were found between those who had experienced an actual loss two months earlier and those who were threatened with a loss. Expected relationships between indices of psychological distress and catecholamine output were not observed. Finally, an association was found between increasing age and higher levels of urinary norepinephrine and epinephrine output among acutely bereaved subjects, suggesting that the adaptation of the sympathetic-adrenal medullary system to stress among older persons is slower.

Acute prolapsed lumbar intervertebral disc. An epidemiologic study with special reference to driving automobiles and cigarette smoking.

An epidemiologic case-control study to identify risk factors for acute prolapsed lumbar intervertebral disc was undertaken in Connecticut during 1979-1981. This paper focuses on nonoccupational factors of possible etiologic significance. Persons in their 30s were affected most frequently. Among surgical cases, the ratio of men to women was 1.5 to 1, while among probable and possible cases not undergoing surgery, the male to female ratio was about 1 to 1. Cigarette smoking in the past year was associated with an increased risk for prolapsed disc. The greater the number of hours spent in a motor vehicle, the higher the risk. Use of Swedish and Japanese cars was associated with a lower-than-average risk, while use of other cars was associated with a higher-than-average risk. For each type of car, older cars were associated with higher risks than newer cars. Variables that did not affect the risk for prolapsed lumbar disc in this study included height, weight, number of pregnancies, number of children, frequency of wearing shoes with high heels, smoking cigars or pipes, and participation in baseball or softball, golf, bowling, swimming, diving from a board, tennis, bicycling or jogging.

Disability and cognitive impairment are risk factors for pneumonia-related mortality in older adults.

The role of functional and cognitive limitations in the risk of pneumonia-related mortality in older adults was examined. As part of a cohort study in 3 communities (East Boston, MA; New Haven, CT; and Iowa and Washington Counties, IA), 6,234 women and 4,035 men ages 65 or older completed baseline interviews between 1981 and 1983 and were followed for up to 6 years. Sex-specific Cox proportional-hazards regression models were used to examine the association of baseline physical and cognitive functioning with report of pneumonia (ICD9 480-486) as an underlying, immediate, or contributing cause of death. During followup, a total of 243 men and 160 women died with pneumonia. Adjusting for age, race, education, evidence of five chronic diseases, and smoking status, a significantly increased risk of pneumonia mortality (P < 0.05) was found for limitations in activities of daily living and cognitive impairment among both men and women. Inability to walk a half mile, climb stairs, or perform heavy housework was significantly associated with increased risk of pneumonia mortality for women but not for men in the same multivariate models. Men and women whose body-mass index was above the median had significantly lower risk of pneumonia mortality compared with those in the lowest quartile. Further elucidation of the sequence between physical and cognitive impairment and risk of pneumonia will be important in reducing pneumonia-associated morbidity and mortality.