The application of evidence-based principles of care in older persons (issue 2): management of lipid disorders

Hypertension in the nursing home

Hypertension in a nursing home patient is a systolic blood pressure of 140 mm Hg or higher and 130 mm Hg or higher in a patient with diabetes mellitus or chronic renal insufficiency, or a diastolic blood pressure of 90 mm Hg or higher and 80 mm Hg or higher in a patient with diabetes mellitus or chronic renal insufficiency. Numerous prospective, double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces the development of new coronary events, stroke, and congestive heart failure in older persons. The goal of treatment of hypertension in elderly persons is to lower the blood pressure to less than 140/90 mm Hg and to less than 130/80 mm Hg in older persons with diabetes mellitus or chronic renal insufficiency. Elderly persons with diastolic hypertension should have their diastolic blood pressure reduced to 80 to 85 mm Hg. Diuretics should be used as initial drugs in the treatment of older persons with hypertension and no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their associated medical conditions. If the blood pressure is more than 20/10 mm Hg above the goal blood pressure, drug therapy should be initiated with 2 antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated in patients with hypertension.

Prevalence of moderate and severe renal insufficiency in older persons with hypertension, diabetes mellitus, coronary artery disease, peripheral arterial disease, ischemic stroke, or congestive heart failure in an academic nursing home

OBJECTIVE

To determine the prevalence of moderate and severe renal insufficiency in older persons in an academic nursing home.

DESIGN

The prevalence of an estimated glomerular filtration rate (GFR) determined by the Modification of Diet in Renal Disease equation less than 60 mL/min/1.73 m(2) was investigated in older persons in an academic nursing home with either hypertension, diabetes mellitus, coronary artery disease (CAD), peripheral arterial disease (PAD), ischemic stroke, or congestive heart failure (CHF).

SETTING

An academic nursing home.

PARTICIPANTS

Two hundred and two persons (104 women and 98 men), mean age 73 years (range 50 to 98 years) residing in an academic nursing home.

MEASUREMENTS

Prevalence of a GFR less than 60 mL/min/1.73 m(2).

RESULTS

A GFR less than 60 mL/min/1.73 m(2) was present in 60 (42%) of 143 persons with hypertension, in 30 (48%) of 62 persons with diabetes mellitus, in 28 (52%) of 52 persons with CAD, in 13 (50%) of 26 persons with PAD, in 10 (44%) of 23 persons with ischemic stroke, and in 15 (63%) of 24 persons with CHF.

CONCLUSION

Older persons with hypertension, diabetes mellitus, CAD, PAD, ischemic stroke, or CHF have a high prevalence of moderate or severe renal insufficiency and should be treated optimally to reduce the increased risk of cardiovascular events and mortality in this high-risk population.

Prevalence of use of antiplatelet drugs, beta blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in older patients with coronary artery disease in an academic nursing home

OBJECTIVE

To determine the prevalence of use of antiplatelet drugs, beta-blockers, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in older persons with coronary artery disease (CAD) in an academic nursing home.

DESIGN

We investigated in all older persons with documented CAD who were not terminally ill in an academic nursing home the prevalence of use of antiplatelet drugs, beta-blockers, statins, and ACE inhibitors or ARBs. The physicians taking care of these persons were taught by one of the authors to treat persons with CAD with these drugs to reduce cardiovascular morbidity and mortality.

SETTING

An academic nursing home.

PARTICIPANTS

Of 202 persons, 54 (27%) had documented CAD. The 54 persons with CAD included 27 women and 27 men, mean age 76 +/- 8 years.

MEASUREMENTS

Prevalence of use of antiplatelet drugs, beta-blockers, statins, and ACE inhibitors or ARBs.

RESULTS

In 54 persons with CAD, aspirin or clopidogrel was used in 53 persons (98%), beta-blockers in 52 persons (96%), statins in 47 persons (87%), and ACE inhibitors or ARBs in 46 persons (85%). The serum low-density lipoprotein cholesterol was less than 100 mg/dL in 51 persons (94%).

CONCLUSION

As recommended by evidence-based guidelines, the prevalence of use of aspirin or clopidogrel was 98%, of beta-blockers was 96%, of statins was 87%, and of ACE inhibitors or ARBs was 85% in an academic nursing home.

Prevalence of a hemoglobin A1c less than 7.0%, of a blood pressure less than 130/80 mm Hg, and of a serum low-density lipoprotein cholesterol less than 100 mg/dL in older patients with diabetes mellitus in an academic nursing home

OBJECTIVE

To determine the prevalence of a hemoglobin A(1c) less than 7.0%, of a blood pressure less than 130/80 mm Hg, and of a serum low-density lipoprotein (LDL) cholesterol less than 100 mg/dL in older persons with diabetes mellitus who were not terminally ill in an academic nursing home.

DESIGN

We investigated in all older diabetic individuals who were not terminally ill in an academic nursing home the prevalence of a hemoglobin A(1c) less than 7.0%, of a blood pressure less than 130/80 mm Hg, and of a serum LDL cholesterol less than 100 mg/dL.

SETTING

An academic nursing home.

PARTICIPANTS

Of 202 persons, 62 (31%) had diabetes mellitus. The 62 diabetic individuals included 33 women and 29 men, mean age 73 +/- 9 years.

MEASUREMENTS

Prevalence of hemoglobin A(1c) less than 7.0%, of blood pressure less than 130/80 mm Hg, and of serum LDL cholesterol less than 100 mg/dL.

RESULTS

The hemoglobin A(1c) was less than 7.0% in 55 (89%) of 62 diabetic individuals. The blood pressure was less than 130/80 mm Hg in 52 (84%) of 62 diabetic individuals. The serum LDL cholesterol was less than 100 mg/dL in 55 (89%) of 62 diabetic individuals.

CONCLUSION

As recommended by the American Diabetes Association, the hemoglobin A(1c) was less than 7.0% in 55 (89%) of 62 diabetic individuals, the blood pressure was less than 130/80 mm Hg in 52 (84%) of 62 diabetic individuals, and the serum LDL cholesterol was less than 100 mg/dL in 55 (89%) of 62 diabetic individuals in an academic nursing home.

Prevalence of adequate and of optimal control of serum low-density lipoprotein cholesterol in an academic nursing home

OBJECTIVE

To determine the prevalence of adequate control of serum low-density lipoprotein (LDL) cholesterol in older persons who were not terminally ill in an academic nursing home.

DESIGN

An increased LDL cholesterol was 100 mg/dL or higher in very high-risk persons with coronary artery disease (CAD), ischemic stroke, peripheral arterial disease, diabetes mellitus, or 2+ risk factors and a 10-year risk for CAD greater than 20%; 130 mg/dL or higher in moderately high-risk persons with 2+ risk factors and a 10-year risk for CAD of 10% to 20%; and 160 mg/dL or higher in low risk persons with 0 to 1 risk factor.

SETTING

An academic nursing home.

PARTICIPANTS

Two hundred and two persons (104 women and 98 men), mean age 73 years (range 50 to 98 years) residing in an academic nursing home.

MEASUREMENTS

Prevalence of use of lipid-lowering drugs and of serum LDL cholesterol less than 100 mg/dL and less than 70 mg/dL in very high-risk persons and less than 130 mg/dL and less than 100 mg/dL in moderately high-risk persons.

RESULTS

Measurements of serum LDL cholesterol were obtained in 135 of 135 very high-risk persons (100%), in 57 of 61 moderately high-risk persons (93%), and in none of 6 low-risk persons (0%). Statins were used in 115 of 135 very high-risk persons (85%) and in 24 of 57 moderately high-risk persons (42%). Ezetimide was used to treat 3 of 135 very high-risk persons (2%). The last serum LDL cholesterol reported was less than 100 mg/dL in 119 of 135 very high-risk persons (93%), less than 70 mg/dL in 108 of 135 very high-risk persons (80%), less than 130 mg/dL in 40 of 57 moderately high-risk persons (70%), and less than 100 mg/dL in 35 of 57 moderately high-risk persons (61%).

CONCLUSION

Serum LDL cholesterol was measured in 192 of 202 older persons (95%) in an academic nursing home. Serum LDL cholesterol was adequately controlled in 93% of very high-risk persons and in 70% of moderately high-risk persons. Serum LDL cholesterol was optimally controlled in 80% of very high-risk persons and in 61% of moderately high-risk persons.