Blood pressure and mortality in old age. Eleven years' follow-up of a 70-year-old population

The impact of cardiovascular health and frailty on mortality for males and females across the life course

BACKGROUND

The effect of frailty and poor cardiovascular health on mortality for males and females is not fully elucidated. We investigated whether the combined burden of frailty and poor cardiovascular health is associated with all-cause and cardiovascular disease (CVD) mortality by sex and age.

METHODS

We analyzed data of 35,207 non-institutionalized US residents aged 20-85 years old (mean age [standard deviation]: 46.6 [16.7 years], 51.4% female, 70.8% White, 10.3% Black, 13.2% Hispanic) from the National Health and Nutrition Examination Survey (1999-2015). Cardiovascular health was measured with the American Heart Association's Life's Simple 7 score (LS7). A 33-item frailty index (FI) was constructed to exclude cardiovascular health deficits. We grouped the FI into 0.1 increments (non-frail: FI < 0.10, very mildly frail: 0.1 ≤ FI < 0.20, mildly frail: 0.20 ≤ FI < 0.30, and moderately/severely frail: FI ≥ 0.30) and LS7 into tertiles (T1[poor] = 0-7, T2[intermediate] = 8-9, T3[ideal] = 10-14). All-cause and CVD mortality data were analyzed up to 16 years. All regression models were stratified by sex.

RESULTS

The average FI was 0.09 (SD 0.10); 29.6% were at least very mildly frail, and the average LS7 was 7.9 (2.3). Mortality from all-causes and CVD were 8.5% (4228/35,207) and 6.1% (2917/35,207), respectively. The median length of follow-up was 8.1 years. The combined burden of frailty and poor cardiovascular health on mortality risk varied according to age in males (FI*age interaction p = 0.01; LS7*age interaction p < 0.001) but not in females. In females, poor FI and LS7 combined to predict all-cause and CVD mortality in a dose-response manner. All-cause and CVD mortality risk was greater for older males (60 and 70 years old) who were at least mildly frail and had intermediate cardiovascular health or worse (hazard ratio [lower/higher confidence interval ranges] range: all-cause mortality = 2.02-5.30 [1.20-4.04, 3.15-6.94]; CVD-related mortality = 2.22-7.16 [1.03-4.46, 4.49-11.50]) but not for younger males (30, 40, and 50 years old).

CONCLUSIONS

The combined burden of frailty and LS7 on mortality is similar across all ages in females. In males, this burden is greater among older people. Adding frailty to assessments of overall cardiovascular health may identify more individuals at risk for mortality and better inform decisions to implement preventative or treatment approaches.

Overall Cardiovascular Health Is Associated With All-Cause and Cardiovascular Disease Mortality Among Older Community-Dwelling Men and Women

OBJECTIVE

The objective of this study was to assess the associations between cardiovascular health and all-cause and cardiovascular disease mortality among community-dwelling elderly.

METHOD

Secondary data analysis was performed using data collected as part of the InCHIANTI cohort procedures and included 928 participants (55% female) aged 65 years and older. Overall cardiovascular health was assessed using seven health behaviors and factors, scored 0 to 14, with higher scores indicating better cardiovascular health, modeled categorically as tertiles. Vitality status was ascertained using registry information. Cox proportional hazards models were used to examine the associations between cardiovascular health and all-cause and cardiovascular disease mortality.

RESULTS

After an average follow-up of 9.1 years, better overall cardiovascular health (highest tertile) was inversely associated with all-cause (hazard ratio [HR] = 0.68, 95% confidence interval [CI] = [0.51, 0.92]) and cardiovascular disease mortality (HR = 0.61, 95% CI = [0.38, 0.97]) compared with the lowest tertile.

DISCUSSION

Cardiovascular health, even in the elderly, is inversely associated with mortality.

A population-based study on brain atrophy and motor performance in elderly women

BACKGROUND

Brain atrophy is a common neuroimaging finding in healthy elderly individuals as well as in patients with movement-related disorders. The relationship between brain atrophy and motor changes has not been frequently reported. This study investigates this relationship.

METHODS

A population-based sample of women (N = 238), aged 70, 74, and 78 years, living in Göteborg, Sweden, participated in this study. Motor performance was measured by a laboratory test, the Postural-Locomotion-Manual test, which precisely measures the subject's mobility of lower and upper extremities using an optoelectronic technique. Cortical and central atrophy were rated on computerized tomographic (CT) scans of the brain.

RESULTS

In bivariate analysis, temporal lobe atrophy, high sylvian fissure ratio, and high bicaudate ratio were correlated with impaired mobility. The association between temporal lobe atrophy and high sylvian fissure ratio and poor mobility remained after controlling for age, smoking, coronary heart disease, diabetes mellitus, hypertension, and white matter lesions on CT scans.

CONCLUSIONS

Our results suggest that temporal lobe atrophy, which is often seen on brain imaging in elderly persons, might be an important brain abnormality related to motor impairments in elderly women. Further studies to investigate this relationship and its underlying mechanisms are needed.

Do racial differences in hypertension persist in successful agers? Findings from the MacArthur Study of Successful Aging

The objective of this study was to determine whether racial differences in hypertension in a random sample of community-dwelling older adults also remained significant in a sample of successful agers. Data for the random sample of community-dwelling older adults came from the Duke University Established Populations for Epidemiologic Studies of the Elderly (4,162 community-dwelling adults age 65 and older) and showed strong racial differences in hypertension. Data for successful agers came from the Duke MacArthur (428 of EPESE respondents in the top 30% in terms of physical, cognitive, and psychosocial performance). The mean of two sitting blood pressure measurements was the dependent variable for both sets of analyses. Independent variables included demographics and health factors. Using logistic regression, odds ratios in the Duke EPESE and Duke MacArthur samples for race were similar (Duke EPESE odds ratio = 1.30; Duke MacArthur odds ratio = 1.29). Sample size differences affected statistical significance. However, race differences in hypertension in older adults appear to be unexplained by socioeconomic status or other usual explanatory variables. Even among successful agers, racial differences in hypertension persist.

Antihypertensive treatment in the elderly

Drug treatment with beta-blockers and diuretics in hypertensive men and women aged 70 and above confers highly significant and clinically relevant reductions in cardiovascular (especially stroke) morbidity and mortality. This satisfactory effect is not impaired by a low tolerability of the drugs used. Furthermore, treatment of elderly hypertensives with beta-receptor blockers and/or diuretics is cost-effective. In STOP-Hypertension the cost-effectiveness ratios were low and of the same magnitude for both men and women. The clinical implication of this is that blood pressure lowering therapy should be considered in elderly hypertensives, at least up until they are 80 years old. It should also be remembered that elderly patients often have other diseases than hypertension and that the drug treatment should be adjusted accordingly, e.g. by using a calcium antagonist or an ACE inhibitor, when indicated.

Hypertension in the elderly

Several studies have demonstrated an increased risk of cardiovascular disease (CVD) in relation to high blood pressure in elderly patients aged below 70-75, whereas the risk seemed to decline with age in the older elderly. Early studies on the effect of treatment of mild to moderate hypertension in the elderly indicated (but did not convincingly show) a reduction of CVD. In the 1980s, both the EWPHE trial (European Working Party on High Blood Pressure in the Elderly) and the HEP study (The Randomised Trial of the Treatment of Hypertension in Elderly Patients in Primary Care) provided evidence of the benefit of treating high blood pressure in the elderly, at least up to the age of 70-74. These results have lately been confirmed by three major trials SHEP (Systolic Hypertension in the Elderly Program), STOP (Swedish Trial in Old Patients with Hypertension) and MRC (Medical Research Council), also including older patients (STOP) and those with isolated systolic hypertension (SHEP). This satisfactory effect was not impaired by a low tolerability of the drugs used (beta-blockers and diuretics). In conclusion, drug treatment with beta-blockers and diuretics in hypertensive men and women aged 70 and above confers highly significant and clinically relevant reductions in cardiovascular (especially stroke) morbidity and mortality. The clinical implication of this is that blood pressure lowering therapy should be considered in elderly hypertensives, at least up until they are 80. It should also be remembered that elderly hypertensives often have other diseases as well and that the drug treatment should be adjusted accordingly.

Marital coital activity in men at the age of 75: relation to somatic, psychiatric, and social factors at the age of 70

OBJECTIVE

To find somatic, psychiatric, and social variables that predicted cessation of coital activity in elderly married men.

DESIGN

Prospective, longitudinal, observational study

SETTING

General survey of a representative sample of 70-year-old urban men (born in 1901-02) in Göteborg, Sweden.

PARTICIPANTS

Forty-one men who were married and had coital activity at age 70 and who, at the age of 75, were still married when the sample was reinterviewed.

MAIN OUTCOME MEASURES

Presence (c) or absence (nc) of coital activity at age 75.

RESULTS

Cessation of coital activity was associated with vasculogenic factors. At least one of the following disorders--systemic hypertension, ischemic heart disease, congestive heart failure, diabetes mellitus, or hypertriglyceridemia--was found in three of the C men and 14 of the NC men, P less than 0.005. Systemic hypertension was the most common disorder and was found in one C man and 10 NC men, P less than 0.01. Cessation of coital activity was associated with specified types of stress between 65 and 70 years of age in the subgroup of men who had stopped due to inability; six out of eight reported stress against five out of 20 in the C group, P less than 0.05. There was no association with any of the psychiatric or social factors studied.

CONCLUSIONS

Cessation of coital activity is predicted by somatic disorders which are associated with vascular damage and especially by hypertension. This observation does not allow the conclusion that antihypertensive treatment would be effective in postponing the cessation of coital activity.

Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension)

Although the benefits of antihypertensive treatment in "young" elderly (under 70 years) hypertensive patients are well established, the value of treatment in older patients (70-84 years) is less clear. The Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) was a prospective, randomised, double-blind, intervention study set up to compare the effects of active antihypertensive therapy (three beta-blockers and one diuretic) and placebo on the frequency of fatal and non-fatal stroke and myocardial infarction and other cardiovascular death in hypertensive Swedish men and women aged 70-84 years. We recruited 1627 patients at 116 health centres throughout Sweden, who were willing to participate, and who met the entry criteria of three separate recordings during a 1-month placebo run-in period of systolic blood pressure between 180 and 230 mm Hg with a diastolic pressure of at least 90 mm Hg, or a diastolic pressure between 105 and 120 mm Hg irrespective of the systolic pressure. The total duration of the study was 65 months and the average time in the study was 25 months. 812 patients were randomly allocated active treatment and 815 placebo. The mean difference in supine blood pressure between the active treatment and placebo groups at the last follow-up before an endpoint, death, or study termination was 19.5/8.1 mm Hg. Compared with placebo, active treatment significantly reduced the number of primary endpoints (94 vs 58; p = 0.0031) and stroke morbidity and mortality (53 vs 29; p = 0.0081). Although we did not set out to study an effect on total mortality, we also noted a significantly reduced number of deaths in the active treatment group (63 vs 36; p = 0.0079). The benefits of treatment were discernible up to age 84 years. We conclude that antihypertensive treatment in hypertensive men and women aged 70-84 confers highly significant and clinically relevant reductions in cardiovascular morbidity and mortality as well as in total mortality.

Hypertension and ageing

Hypertension is a common problem in the elderly with a prevalence approaching or exceeding 50%. The risk of cardiovascular disease and death is increased in elderly hypertensives aged 60-74 years, whereas this increased risk seems to be diminished or even nonexistent in those aged 75 and above. Hypotensive drug treatment has been shown to be beneficial for the younger elderly patients, but whether or not this is also true for the older elderly hypertensives is less clear. Isolated systolic hypertension increases the cardiovascular risk, but we lack data on the efficacy of treatment in this group.

Pharmacokinetics and blood pressure effects of felodipine in elderly hypertensive patients. A comparison with young healthy subjects

The pharmacokinetics and antihypertensive effects of felodipine, a new dihydropyridine calcium channel blocker, were studied in elderly hypertensive patients, 67 to 79 years of age and in young healthy subjects, 20 to 34 years of age following oral administration of 5 mg twice daily to steady-state. A single intravenous dose of 3H-felodipine (0.04mg) was given together with the oral dose on the study day. Cmax (17 nmol/L), Cmin (5 nmol/L) and AUC (82 nmol/L.h) were 3 times higher in the elderly than in the young subjects. Systemic availability was about 15% in both groups. Plasma clearance (CL) was reduced from 56.1 L/h in the young to 25.4 L/h in the elderly. There was no effect of age on the volume of distribution at steady-state (Vss). Reduced hepatic blood flow and enzyme activity or increased gut wall metabolism are possible reasons for the altered pharmacokinetics in the elderly. Blood pressure was reduced in the elderly from 190/99 to 177/91 mm Hg 12 hours after 5mg felodipine during twice daily dosage. The effect on blood pressure correlated with plasma concentrations of felodipine.