Nutritional contributors to cardiovascular disease in the elderly

Physiological stress responses in Filipino-American immigrant nurses: the effects of residence time, life-style, and job strain

OBJECTIVE

The purpose of this study was to evaluate the relationship between measures of Americanization (the adoption of American life-style and culture) and physiological measures of stress in Filipino-American immigrants.

METHODS

Ambulatory blood pressure monitors and timed urine collections were used to evaluate blood pressure and urinary catecholamine excretion across the work, home, and sleep daily settings among 31 healthy, premenopausal, immigrant Filipino-American women employed as nurses or nurse's aides. Migration history and life-style were evaluated from questionnaire responses. Reported job strain, decision latitude, and psychological demand were obtained from the Job Content Questionnaire.

RESULTS

Immigrants who had lived longer in the United States had elevated norepinephrine levels in the work and home settings (p < .05), higher diastolic blood pressure during sleep (p < .01), and lower dips in blood pressure during sleep (p < .05). Job strain measures were not related to blood pressure, catecholamine excretion rates, or residence time in the United States.

CONCLUSIONS

The results suggest that indicators of stress increase as a function of time since immigration, although this result is not explained by self-reports of identification with Filipino or American life-style or by measures of job strain.

Prevention of cardiovascular events in elderly hypercholesterolemic patients

The management of hyperlipidemia in the elderly patient is a major problem, given the frequency of dyslipidemias and cardiovascular disorders in this age group. Therapy must take current uncertainties into account and, in the absence of therapeutic studies carried out in the elderly, is typically based upon a case-by-case approach. Raised cholesterol levels remain a significant risk factor for coronary heart disease (CHD) in the elderly. Although the relative risk of CHD tends to diminish with increasing age, this reduction is accompanied by an increase in absolute risk (ie, the number of events) as the frequency of the illness increases markedly with age. The results of major outcome studies with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), when analyzed according to patient age, indicate that the benefits of these agents are not merely confined to younger individuals. However, the elderly form a unique patient population--the proportion of women is greater and the profile of cardiovascular illnesses is characterized, among others, by a greater incidence of cerebrovascular accidents. Problems relating to poor tolerability and comorbidity (which may give rise to drug-drug interactions) also occur more frequently in this age group. Moreover, the potential widespread treatment of hyperlipidemia in the elderly has profound economic implications. Under these circumstances, the clinical practice recommendations depend upon a reasonable extrapolation of epidemiologic and therapeutic data obtained from middle-aged men. At present, treatment is therefore aimed at patients with the most severe forms of hyperlipidemia, generally in the secondary prevention setting, taking into account the patient's life expectancy. The results of ongoing studies will determine the benefits of lipid-lowering therapy for primary prevention of CHD in the elderly.

The estimated costs and savings of medical nutrition therapy: the Medicare population

OBJECTIVES

To measure the potential savings from medical nutrition therapy (MNT) and to estimate the net cost to Medicare of covering these services for Medicare enrollees. This includes developing an estimate of the cost of providing medical nutrition services to the Medicare population and estimating the savings in hospital and other spending resulting from the use of these services.

DESIGN

Analysis of longitudinal data from the Group Health Cooperative of Puget Sound (Seattle, Wash) for persons aged 55 years and older who have coverage for MNT services.

SUBJECTS/SETTING

Persons aged 55 years and older who had diabetes (n = 12,308), cardiovascular disease (n = 10,895), or renal disease (n = 3,328) and who were covered under the Group Health Cooperative of Puget Sound, including Medicare beneficiaries enrolled in the plan's Medicare risk contract program. Extrapolation to the US Medicare population is based on data for persons served by the Group Health Cooperative of Puget Sound.

INTERVENTION

The use of MNT.

MAIN OUTCOMES MEASURE

Differences in health care utilization levels of persons with diabetes, cardiovascular disease, and renal disease who do and do not receive MNT. Differences in utilization were estimated for hospital discharges per calendar quarter, physician visits per quarter, and other outpatient visits per quarter.

STATISTICAL ANALYSES PERFORMED

Multivariate regression models of changes in utilization for persons after they receive MNT services.

RESULTS

Our analysis showed that MNT was associated with a reduction in utilization of hospital services of 9.5% for patients with diabetes and 8.6% for patients with cardiovascular disease. Also, utilization of physician services declined by 23.5% for MNT users with diabetes and 16.9% for MNT users with cardiovascular disease. The net cost of covering MNT under Medicare is estimated to be $369.7 million over the 1998 through 2004 period. The total cost of benefits is estimated to be $2.7 billion over this period. This would be partially offset by estimated savings of $2.3 billion resulting in net costs of $369.7 million. The program would actually yield net savings after the third year of the program, which would continue through 2004 and beyond.

CONCLUSION

After an initial period of implementation, coverage for MNT can result in a net reduction in health services utilization and costs for at least some populations. In the case of persons aged 55 years and older, the savings in utilization of hospital and other services will actually exceed the cost of providing the MNT benefit. These results suggest that Medicare coverage of MNT has the potential to pay for itself with savings in utilization for other services.

Long-term efficacy and tolerability of simvastatin in a large cohort of elderly hypercholesterolemic patients

The long-term efficacy and tolerability of simvastatin, a 3-hydroxy-3-methylglutaryl-co-enzyme A (HMG-CoA) reductase inhibitor, was assessed during a 24-month follow-up period in 168 elderly hypercholesterolemic patients. After completing a 4 week double blind dose ranging study with simvastatin, 47 males and 122 females over 62 years of age with type II hyperlipidemia, a total cholesterol level above 6.5 mmol/l and clinically manifest cardiovascular disease were included in this extended study. A total of 159 patients completed the 12-month follow-up period and 141 patients were monitored over the full 24 months. All patients were started on 10 mg simvastatin once daily and the dosage was increased until the target levels of low density lipoprotein (LDL) cholesterol between 2.3 mmol/l (90 mg/dl) and 3.6 mmol/l (140 mg/dl) were reached. Fifty percent of patients reached the targeted LDL cholesterol goal of < 3.6 mmol/l (140 mg/dl) during the study. At study completion, 65 patients (39%) were taking 40 mg simvastatin per day, 56 patients (33%) 20 mg, 42 patients (25%) 10 mg and 5 patients (3%) only used 5 mg per day. Sixteen patients (9%) received concomitant lipid lowering therapy. Over 2 years, the mean decrease in LDL cholesterol ranged from 36% to 38%, the median decrease in triglycerides was 12% to 19% and the mean increase in high density lipoprotein (HDL) cholesterol ranged from 9% to 10%, respectively. Seven patients discontinued simvastatin because of adverse clinical or laboratory events, but only in two (1.1%) was this considered to be drug-related. Side-effects were mild and most frequently gastrointestinal in nature. Mean changes in asparate aminotransferase (AST) were not significantly different from zero and mean changes in alanine aminotransferase (ALT) and creatine phosphokinase (CPK) showed a small increase. We conclude that simvastatin is an efficacious and well-tolerated treatment for hypercholesterolemia in elderly individuals for extended periods.

A review of observational studies on the relationship between cholesterol and coronary heart disease

The likelihood that an association observed in epidemiological studies is one of cause and effect is often evaluated using criteria first put forward by Bradford Hill. The evidence on whether abnormal concentrations of cholesterol and lipoproteins in the blood plasma cause coronary heart disease (CHD) is considered using Bradford Hill's criteria. Evidence from observational studies, backed by evidence from clinical, animal and laboratory studies, leaves no doubt that a high plasma cholesterol concentration is a cause of CHD.

Serum total cholesterol and systolic blood pressure as risk factors for mortality from ischemic heart disease among elderly men and women

Serum total cholesterol (TC) and systolic blood pressure (SBP) were investigated as risk factors for mortality from ischemic heart disease among 272 elderly men and women during 17 years of follow-up. For men, TC was not significantly associated with mortality from ischemic heart disease. Among women, a significant positive association was found (p-trend = 0.03 when adjusted for age, body mass index, SBP, alcohol consumption, smoking, and the prevalence of myocardial infarction, angina pectoris and diabetes mellitus). Among women a significant positive association was also observed for SBP after adjustment for all potential confounders (p-trend = 0.05). Among men, the adjusted association with SBP was not statistically significant. The results suggest that TC and SBP are stronger independent risk factors for mortality from ischemic heart disease among elderly women than among elderly men. These differences between genders may be due to selective mortality among middle-aged men and physiological changes in women during menopause.

Adverse effects of abdominal obesity on lipoprotein lipids in healthy older men

Individuals with abdominal obesity are at increased risk for the development of coronary artery disease (CAD). This study examines whether an abdominal fat distribution, indexed by the waist to hip ratio (WHR), is associated with an atherogenic lipoprotein lipid profile independent of the degree of obesity (percent body fat) and maximal aerobic capacity (VO2max) in 127 older (60 +/- 8 years, mean +/- SD) normotensive, nonsmoking, nondiabetic men. Compared to men with WHR below the population mean (< 0.96, low WHR), men with high WHR (> 0.96) had higher triglycerides (TG) (124 +/- 47 vs. 93 +/- 48 mg/dl, p < 0.001) and lower high density lipoprotein cholesterol (HDL-C) (34 +/- 7 vs 41 +/- 9 mg/dl, p < 0.001) levels with no difference in low density cholesterol (LDL-C) levels. Plasma TG levels were positively associated with both percent body fat (r = 0.50, p < 0.0001) and WHR (r = 0.49, p < 0.0001), and negatively with VO2max (r = -0.36, p < 0.0001), whereas plasma HDL-C levels were negatively associated with percent body fat (r = -0.50, p < 0.0001) and WHR (r = -0.54, p < 0.0001), and positively with VO2max (r = 0.45, p < 0.0001). Independent relationships between WHR and both plasma TG (r = 0.30, p < 0.001) and HDL-C (r = -0.34, p < 0.0001) remained after correction for both percent body fat and VO2max. Using analysis of covariance, the differences in TG and HDL-C between groups remained after adjustment for percent body fat and VO2max. These results suggest that in older men, an abdominal distribution of body fat, independent of both percent body fat and VO2max, is associated with elevated TG and low HDL levels, thus increasing the risk for CAD.

Diet in the elderly. Needs and risks

Aging individuals have decreased caloric intake associated with increases in body fat and decreases in lean body mass. Calcium and vitamin D supplements are necessary for certain elderly populations, whereas the recommended intake of fat, protein, and trace elements does not change substantially with age. Malnutrition is very common in ill, elderly patients and is frequently missed or often not treated by physicians. This article reviews these findings and recommendations.

Improving dietary practices of elderly individuals: the power of prompting feedback, and social reinforcement

Three intervention packages consisting of (a) enhanced prompts, feedback, and social reinforcement; (b) a lottery; and (c) serving as a confederate were added and removed in sequence as adjacent conditions in an extended withdrawal design to assess their effects on the dietary choices of elderly persons. Participants were 3 elderly residents of an independent living facility who were identified as making consistently poor dietary choices and who had medical conditions that necessitated changes in their eating habits. All 3 participants demonstrated a marked increase in healthy choices of food items in response to the package of enhanced prompts, feedback, and social reinforcement. No additional increase occurred with the introduction of the lottery and serving as a confederate. Food-choice data indicated that most of these improvements could be attributed to healthier entree and dessert choices. Group data for all residents suggested small improvements in dietary practices during the three intervention conditions, with the largest proportion of the group's healthy choices occurring when the lottery was added to enhanced prompts, feedback, and social reinforcement. Food-choice data indicated that most of these improvements could be attributed to healthier dessert choices alone.

A longitudinal study on glucose tolerance and other cardiovascular risk factors: associations within an elderly population

From 1971 until 1975, 204 patients from a general practice, aged 64-87 at entry, were examined annually. At every examination body weight, serum lipids, and systolic blood pressure were measured, and a complete glucose tolerance test was carried out. Clinically diagnosed diabetics were excluded. Adjusted for age and sex, the annual change in the area under the glucose curve (AUC) was significantly associated with body weight change. Changes in serum total cholesterol, serum triglycerides, and systolic blood pressure were also associated with body weight change. The results were independent of potential confounders such as alcohol use, smoking habits, presence of cardiovascular disease, and baseline levels of the different risk factors. The change in AUC was also associated with changes in serum total cholesterol, independent of confounders such as body weight. Changes in AUC were not related to changes in systolic blood pressure and serum triglycerides. The results of this study suggest that changes in glucose tolerance are not only related to changes in body weight, but also to changes in serum cholesterol.

Clinical considerations regarding treatment of hypercholesterolemia in the elderly

Therapy for hypercholesterolemia has been shown to reduce the risk for coronary heart disease in middle-aged men. Current guidelines for detecting and treating hypercholesterolemia in adults render large numbers of elderly patients eligible for medical intervention. The elderly are a heterogeneous group of individuals who differ widely in their ability to function physically, behaviorally, cognitively and emotionally. Not all elderly patients qualify for cholesterol-lowering therapy. Decisions regarding diagnostic and therapeutic interventions should be based on the physiological age of the patient rather than the chronological age, and on the presence and severity of concomitant disease, mental status and cognitive ability, as well as on the patient's expectations from medical care. Suggestions for dietary therapy and drug therapy in the elderly are provided. The objectives and potential benefits of therapy are described. Based on the information currently available, it is concluded that the elderly are likely to benefit from cardiovascular risk factor modification and should not be denied cholesterol-lowering therapy simply on the basis of their chronological age.

Is early natural menopause a biologic marker of health and aging?

The relation between age at natural menopause and all-cause mortality was investigated in a sample of 5,287 White women, ages 55 to 100 years, naturally-postmenopausal, Seventh-day Adventists who had completed mailed questionnaires in 1976. The age-adjusted odds ratio of death during 1976-82 in women with natural menopause before age 40 was 1.95 (95% confidence interval = 1.24, 3.07), compared to the reference group of women reporting natural menopause at ages 50 to 54. Corresponding odds ratios of death were 1.39 (95% CI = 1.06, 1.81) for natural menopause at ages 40 to 44, and 1.03 (95% CI = 0.84, 1.25) for natural menopause at ages 45 to 49. Among 3,166 White, 55- to 100-year-old, surgically-postmenopausal, Adventist women, there was no relation between age at surgical menopause and mortality. Logistic regression analyses indicated that findings from this study were apparently not due to confounding by smoking, over- or underweight, reproductive history, or replacement estrogen use.

Cholesterol as risk factor for mortality in elderly women

92 women aged 60 years and over (mean 82.2, SD 8.6) living in a nursing home and free from overt cancer were followed-up for 5 years. 53 died during this period; necropsy revealed cancer in only 1 patient. Serum total cholesterol at entry ranged from 4.0 to 8.8 mmol/l (mean 6.3, SD 1.1). Cox's proportional hazards analysis showed a J-shaped relation between serum cholesterol and mortality. Mortality was lowest at serum cholesterol 7.0 mmol/l, 5.2 times higher than the minimum at serum cholesterol 4.0 mmol/l, and only 1.8 times higher when cholesterol concentration was 8.8 mmol/l. This relation held true irrespective of age, even when blood pressure, body weight, history of myocardial infarction, creatinine clearance, and plasma proteins were taken into account. The relation between low cholesterol values and increased mortality was independent of the incidence of cancer.

Hypertension and other risk factors in coronary heart disease

Whether systolic or diastolic, labile or fixed, at any age in either sex, hypertension is dangerous. Adiposity, heart rate, alcohol intake, hematocrit, blood sugar, serum cholesterol, and triglycerides are all related to the occurrence of hypertension in one or both sexes. These factors also contribute to the occurrence of the cardiovascular sequelae of hypertension. The influence of blood pressure on the incidence of cardiovascular disease is independent of other predisposing cofactors but is greatly affected by them. Elevated pressures are often accompanied by hyperlipidemia, hyperglycemia, elevated fibrinogen, and ECG abnormalities, all of which augment the risk. Coronary disease is now the most common sequela of hypertension, and the excess risk is concentrated in those with an increased low-density lipoprotein/high density lipoprotein ratio, impaired glucose tolerance, and ECG abnormalities, and in cigarette smokers. Hypertension is only a component of a multifactorial coronary risk profile which must be considered when implementing optimal therapy. Both the urgency for treatment and judgment of efficacy should be guided by the multivariate risk profile.