The contribution of depression to mortality among elderly with self-reported hypertension: analysis using a national representative longitudinal survey

Prevalence, numbers and mortality risk of hypertensive patients with depressive symptom in China

BACKGROUND

China is currently grappling with the escalating burden of hypertension and depression. This study aimed to assess the prevalence and number of hypertensive patients with depressive symptom, and to evaluate their risk of all-cause mortality.

METHODS

Data from the China Health and Retirement Longitudinal Study (CHARLS) were utilized to estimate the prevalence of individuals with both hypertension and depressive symptom, the recommendation rate for antihypertensive medications, the blood pressure control rate, and the corresponding population size. The Cox proportional hazard model was employed to estimate the risk of all-cause mortality associated with hypertension combined with depressive symptom.

RESULTS

Overall, 15.01% (95% CI: 13.80, 16.31) of adults, corresponding to 72.06 million (95% CI: 66.91, 77.23) individuals, were identified as having both hypertension and depressive symptom. Among these, 28.49 million (95% CI: 27.07, 29.92) were recommended to initiate blood pressure medications but did not comply. Furthermore, 19.53 million (95% CI: 18.01, 21.06) hypertensive patients with depressive symptom who were taking antihypertensive medications did not achieve their blood pressure control goals. Hypertension combined with depressive symptom was associated with an increased risk of all-cause mortality (hazard ratio = 2.21, 95% CI: 1.48, 3.31).

CONCLUSIONS

Our findings indicated a significant population of individuals with both hypertension and depressive symptom in China, with low treatment and control rates. The coexistence of hypertension and depression was linked to a heightened risk of all-cause mortality. Strategies for hypertension prevention and treatment should be integrated with considerations for depression.

CLINICAL TRIAL NUMBER

Not applicable.

Prospective association of comorbid hypertension and depressive symptoms with C-reactive protein in older adults

BACKGROUND

Hypertension and depressive symptoms often occur together in the older population, and each has been separately linked to elevated C-reactive protein (CRP). This study investigated the prospective association between comorbid hypertension and depressive symptoms and high-sensitivity CRP (hs-CRP) in a Chinese older population.

METHODS

This study used data from 4978 participants aged 50 and above, who took part in two waves (2011 and 2015) of the China Health and Retirement Longitudinal Study (CHARLS). Hypertension, depressive symptoms and hs-CRP were measured. Logistic regressions adjusted for confounding variables were used to examine the association between the baseline comorbidity of hypertension and depressive symptoms and the change in hs-CRP levels.

RESULTS

Hypertension and depressive symptoms did not show independent associations with an elevated level of hs-CRP. Participants with comorbid hypertension and depressive symptoms were more likely to develop a higher level of hs-CRP at follow-up (OR = 1.39, 95 % CI: 1.12-1.74) even after adjusting for covariates. Sex- and age-stratified analyses indicated that the association between the comorbidity and higher levels of hs-CRP were prone to be observed in women (OR = 1.55, 95 % CI: 1.16-2.08) and older adults (OR = 1.74, 95 % CI: 1.20-2.52).

CONCLUSIONS

Comorbid hypertension and depressive symptoms is related to a higher risk of elevated hs-CRP levels. This association appears to be more pronounced among women and older adults compared to their counterparts.

LIMITATION

Depression was self-reported by participants, which might be considered less unreliable than clinical diagnoses.

Association of hypertension and depression with mortality: an exploratory study with interaction and mediation models

BACKGROUND

The association of hypertension and depression with mortality has not been fully understood. We aimed to explore the possible independent or joint association of hypertension and depression with mortality. Their interaction effects on mortality and possible mediating role were also investigated.

METHODS

Associations of hypertension, depression, and their interaction with all-cause and cardiovascular disease (CVD) mortality were evaluated using multivariate Cox proportional hazards regression models. The mediation analysis was conducted with a Sobel test.

RESULTS

A total of 35152 participants were included in the final analysis. Hypertension and depression were independently associated with increased risk of all-cause and CVD mortality. The co-existence of hypertension and depression resulted in a 1.7-fold [95% confidence interval (CI): 1.3-2.1] increase in all-cause mortality and a 2.3-fold (95% CI: 1.4-3.7) increase in CVD mortality compared to those with neither of them. Hypertension and depression showed no significant multiplicative (P for interaction, 0.587) and additive interaction (P for relative excess risk of interaction, 0.243; P for Interaction on additive scale, 0.654) on all-cause mortality, as well as on CVD mortality. Depression did not mediate the relationship between hypertension and all-cause (Z=1.704, P=0.088) and CVD mortality (Z=1.547, P=0.122). Hypertension did not mediate the relationship between all-cause and CVD mortality as well.

CONCLUSION

Hypertension and depression were related to all-cause and CVD mortality independently and the co-existence of them increased the risk of mortality. However, there is no interaction effect of them on mortality, and hypertension or depression did not mediate the association of each other with mortality.

The association between recreational physical activity and depression in the short sleep population: a cross-sectional study

BACKGROUND

Short sleep is more common in the modern society. Recreational physical activity (RPA) like exercise brings both mental and physiological benefits to depression; paradoxically, lack of sleep is harmful. Evidence on the association between RPA and depression in the short sleep population is limited.

METHODS

Participants with short sleep condition from the National health and Nutrition Examination Surveys (NHANES 2007-2018) were included in the present study. Short sleep condition was defined as ≤ 7 h per night. Sleep duration and RPA status were self-reported in NHANES by the Physical Activity Questionnaire using a 7-day recall method. Multivariable logistic regression was applied to evaluate the association between RPA and depression. Additionally, the non-linear relationship between RPA and depression was evaluated using the threshold effect analysis and restricted cubic spline.

RESULTS

This cross-sectional study comprised 6,846 adults' data, and the weighted participants were 52,501,159. The weighted prevalence of depression was higher in females, which took up 65.85% of all depression patients. In fully adjusted models, sufficient volume of RPA was associated with lower depression risks, with OR (95% CI) =0.678 (0.520, 0.883). Further analysis revealed a U-shaped association between RPA and incident depression, and the inflection point was 640 MET-minutes/week. When RPA <640 MET-minutes/week, increased RPA was associated with lower risk of incident depression, with OR (95% CI) = 0.891 (0.834, 0.953). When RPA ≥ 640 MET-minutes/week, the benefits of RPA seemed to be not significant, with OR (95% CI) = 0.999 (0.990, 1.009).

CONCLUSION

Our findings observed associations between RPA condition and incident depression in the short sleep population. Moderate RPA was beneficial to maintain mental health and associated with lower incidence of depression for short sleepers, but excessive RPA might increase the risk of depression. For general short sleepers, keeping the RPA volume approximately 640 MET-minutes/week was beneficial to lower risks of depression. Gender difference should be considered as an important factor for further studies to examine these relationships and explore mechanisms.

Association of depression with all-cause and cardiovascular mortality among US adults with high and low baseline risk of cardiovascular disease

The intervention of depression was considered a prevention and treatment option for cardiovascular disease (CVD). However, evidence regarding whether association of depression with mortality differed among people at high or low risk of CVD yielded conflicting results. We aimed to investigate associations between depression and all-cause and CVD mortality among 3854 and 3044 US adults at high and low baseline risk of CVD, respectively. Among participants at high risk of CVD, depression and per 5-point increase in PHQ-9 score were associated with 81% (HR=1.81, 95%CI: 1.15-2.86) and 33% (HR=1.33, 95%CI: 1.14-1.55) increased all-cause mortality, respectively. We did not find statistically significant associations between depression (HR=1.40, 95%CI: 0.67-2.95) and PHQ-9 score (HR=1.28, 95%CI: 1.00-1.63) with CVD mortality due to a small number of mortality events. Among people with low risk of CVD, each 5-point increment in PHQ-9 score was associated with all-cause mortality (HR=1.26, 95%CI: 1.02-1.56), while there was no statistically significant association of depression with all-cause mortality (HR=1.69, 95%CI: 0.75-3.81) and CVD mortality (HR=1.99, 95%CI: 0.83-4.81). This study found that depression was associated with all-cause mortality among individuals at a high baseline risk of CVD, but no significant association was observed in people at a low baseline risk of CVD.

Symptom experiences in hypertension: a mixed methods systematic review

AIM

Understanding patients' hypertension (HTN) symptoms can assist healthcare professionals' awareness of individual, cultural, and behavioral responses and improve diagnostic accuracy to optimize treatment. The purpose of this review was to evaluate and synthesize current literature exploring HTN symptoms.

METHODS

Databases searched included MEDLINE (PubMed), CINAHL (EBSCO), Scopus, and Web of Science from January 2010 to January 2022. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The McMaster critical review forms were used to determine the quality of both qualitative and quantitative articles. Synthesis of the data was guided by the Joanna Briggs Institute Convergent Integrated Approach to Mixed Study Systematic Reviews.

RESULTS

In total, 41 articles were included, nine qualitative studies and 32 quantitative. The quality of the articles varied. Symptoms included commonly reported symptoms and some less prevalent, including some reporting absence of symptoms. Factors that affected symptoms included culture, beliefs, psychosocial factors, and knowledge. We also found that there may be a bidirectional relationship between symptoms and behaviors that may lead to self-management.

CONCLUSION

HTN is common and symptoms are frequently reported. HTN management is related to multiple factors. Symptoms continue in a number of individuals after initial diagnosis. Evaluating symptoms after initial diagnosis may help to optimally manage and meet blood pressure guidelines.

Adherence to prescribed antihypertensive medication among patients with depression in the United States

BACKGROUND

Hypertensive patients with depression have a higher mortality rate and a worse prognosis compared with hypertensive only. Depression may reduce medication adherence in hypertension patients.

METHODS

This study includes respondents in the National Health and Nutritional Examination Survey (NHANES) database from 2005 to 2018 who had previously been diagnosed with hypertension. Medication adherence was defined as taking medication as recommended by a physician. The depressive state was assessed using the patient health questionnaire (PHQ)-9.

RESULTS

Nine thousand one hundred eighty-six respondents were included in the analysis. Medication adherence was associated with depression (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.26 to1.75) and depression score (OR: 1.04 per each point increase, 1.03 to 1.05) in the unadjusted analyses. After adjusting for clinical and socioeconomic/demographic factors, there were significant statistical correlations between depression score and medication adherence (aOR: 1.02 per each point increase, 1.00 to 1.03, p < 0.05), but there was no significant statistical correlation between depression and medication adherence (p > 0.05). It was still statistically significant relationships between sex, age, body mass index (BMI), race, marital status, and health insurance with medication adherence after adjusted socioeconomic/demographic factors.

CONCLUSION

Depression was marginally associated with poor medication adherence in hypertensive patients, and the correlation increased with depression degree. Moreover, socioeconomic/demographic factors have an independent impact on medication adherence including sex, age, BMI, race, marital status, and health insurance.

Association between physical activity dimensions and the risk of hypertension among middle and older adults: A cross-sectional study in China

Background

It is known that insufficient physical activity is associated with the risk of hypertension, but the relationship to different physical activity dimensions within hypertension risk remains to be elucidated.

Objective

The objective of this study is to identify the association between physical activity intensity, frequency, duration, and volume with hypertension risk. Meanwhile, a dose-response experiment is conducted to determine the relationship between physical activity level and hypertension risk.

Methods

Data came from the 2018 China Health and Retirement Longitudinal Study (CHARLS, 2018), which included 14266 participants over the age of 45. Binary logistic regression models were established to assess the associations between different dimensions of physical activity and the risk of hypertension. Restricted cubic spline analysis was used to examine possible non-linear associations between physical activity volume and hypertension risk.

Results

For frequency, lower hypertension risk was associated with performing vigorous physical activity 6-7d/w (OR 0.82, 95%CI 0.73-0.93) and moderate physical activity 6-7d/w (OR 0.89, 95%CI 0.80-0.99). No significant association between any light physical activity frequency and hypertension was observed before and after being adjusted. For the duration, lower hypertension risk was observed in performing vigorous physical activity ≥240 min/d (OR 0.85, 95%CI 0.75-0.97) and moderate physical activity ≥240 min/d (OR 0.83, 95%CI 0.71-0.97). For volume, the risks of hypertension in the participants who reported TPA in the 3th and 4th of quantiles were reduced by 18% (OR 0.82, 95%CI 0.72-0.95) and 22% (OR 0.78, 95%CI 0.68-0.91). A non-linear dose-response association between total physical activity and the risk of hypertension was shown among all of the participants (P non-linearity < 0.05).

Conclusion

Higher frequency and longer duration of vigorous physical activity or moderate physical activity were significantly associated with a lower risk of hypertension. Higher physical activity levels were associated with a lower risk of hypertension and there was an inverse non-linear dose-response relationship between weekly total physical activity and the risk of hypertension. These findings provide further proof that hypertension could be prevented through increased physical activity.

Economic Burden of Depressive Symptoms Conditions among Middle-Aged and Elderly People with Hypertension in China

People with hypertension are more prone to incur depressive symptoms, while depressive symptoms have an obvious influence on the healthy functioning, treatment, and management of hypertensive patients. However, there have been limited studies on the association between depression and the economic burden of hypertension. We used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) to estimate the additional annual direct and indirect economic burden of depressive symptoms among middle-aged and elderly hypertensive patients with a multivariable regression model. The depressive symptoms were associated with substantial additional direct and indirect economic burden. Compared with non-co-MHDS (non-co-morbid hypertension and depressive symptoms) patients, the direct economic burden of lower co-MHDS (co-morbid hypertension and depressive symptoms) patients and higher co-MHDS patients increased 1887.4 CNY and 5508.4 CNY, respectively. For indirect economic burden, the lower co-MHDS patients increased 331.2 CNY and the higher co-MHDS patients increased 636.8 CNY. Both direct and indirect economic burden were incremental with the aggravation of depressive symptoms. The results showed depressive symptoms increased total healthcare costs by increasing the utilization and expenditure of primary healthcare services. Depressive symptoms also led to economic loss of productivity, especially for agricultural workers. This study highlights the importance of mental healthcare for hypertensive patients.

Mental health problems and hypertension in the elderly: Review from the HOPE Asia Network

The "triple burden" of aging population, hypertension, and mental health problems making elderly in Asia is more vulnerable. There is evidence of a bidirectional relationship between mental health and hypertension, which results in lower quality of life, lower rate of treatment adherence, and higher mortality among elderly individuals. It is essential to overcome known barriers and care for the elderly with high-risk factors in order to address these burdens. This review revealed that elderly with hypertension were more likely to suffer from depression and anxiety. Therefore, debunking myths, creating awareness regarding mental health, and increasing access to mental health resources through holistic community-based programs would greatly reduce such problems and optimize the chances of success in controlling hypertension-related problems.

Household debt, hypertension and depressive symptoms for older adults

OBJECTIVES

The Chinese household debt has been increasing rapidly in recent years because of the expansion of consumers' spending and mortgage. Its effects on individuals' mental and physical well-being are poorly known. This study aims to examine the relationship of household debt with hypertension and depressive symptoms among the middle- and old-aged population.

METHODS

Nationally representative data were collected from China Health and Retirement Longitudinal Study 2015. Logistic regression analysis and mediation analysis were used to estimate associations of household debt with the presence of hypertension and depressive symptoms. The Sobel test was used to assess the mediation effect of depressive symptoms in the association of household debt and hypertension.

RESULTS

Among 12 274 subjects, those with high-level household debt exhibited 12% increased odds of hypertension and double odds of depressive symptoms compared to low-level household debtors. Household debt had a direct effect on hypertension and depressive symptoms and an indirect effect on hypertension via depressive symptoms.

CONCLUSIONS

The relationships between household debt, depressive symptoms, and hypertension form a society-psychology-body view that is worth considering in household, community and clinical settings in hypertension management among middle-aged and elderly populations.

Impact of major depression on cardiovascular outcomes for individuals with hypertension: prospective survival analysis in UK Biobank

OBJECTIVES

To assess whether a history of major depressive disorder (MDD) in middle-aged individuals with hypertension influences first-onset cardiovascular disease outcomes.

DESIGN

Prospective cohort survival analysis using Cox proportional hazards regression with a median follow-up of 63 months (702 902 person-years). Four mutually exclusive groups were compared: hypertension only (n=56 035), MDD only (n=15 098), comorbid hypertension plus MDD (n=12 929) and an unaffected (no hypertension, no MDD) comparison group (n=50 798).

SETTING

UK Biobank.

PARTICIPANTS

UK Biobank participants without cardiovascular disease aged 39-70 who completed psychiatric questions relating International Classification of Diseases-10 Revision (ICD-10) diagnostic criteria on a touchscreen questionnaire at baseline interview in 2006-2010 (n=134 860).

PRIMARY AND SECONDARY OUTCOME MEASURES

First-onset adverse cardiovascular outcomes leading to hospital admission or death (ICD-10 codes I20-I259, I60-69 and G45-G46), adjusted in a stepwise manner for sociodemographic, health and lifestyle features. Secondary analyses were performed looking specifically at stroke outcomes (ICD-10 codes I60-69 and G45-G46) and in gender-separated models.

RESULTS

Relative to controls, adjusted HRs for adverse cardiovascular outcomes were increased for the hypertension only group (HR 1.36, 95% CI 1.22 to 1.52) and were higher still for the comorbid hypertension plus MDD group (HR 1.66, 95% CI 1.45 to 1.9). HRs for the comorbid hypertension plus MDD group were significantly raised compared with hypertension alone (HR 1.22, 95% CI 1.1 to 1.35). Interaction measured using relative excess risk due to interaction (RERI) and likelihood ratios (LRs) were identified at baseline (RERI 0.563, 95% CI 0.189 to 0.938; LR p=0.0116) but not maintained during the follow-up.

LIMITATIONS

Possible selection bias in UK Biobank and inability to assess for levels of medication adherence.

CONCLUSIONS

Comorbid hypertension and MDD conferred greater hazard than hypertension alone for adverse cardiovascular outcomes, although evidence of interaction between hypertension and MDD was inconsistent over time. Future cardiovascular risk prediction tools may benefit from the inclusion of questions about prior history of depressive disorders.

Association of depression with mortality in an elderly treated hypertensive population

ABSTRACTBackground:Both elevated blood pressure and/or depression increase the risk of cardiovascular disease and mortality. This study in treated elderly hypertensive patients explored the incidence of depression, its association (pre-existing and incident) with mortality and predictors of incident depression.

METHODS

Data from 6,083 hypertensive patients aged ≥65 years enrolled in the Second Australian National Blood Pressure study were used. Participants were followed for a median of 10.8 years (including 4.1 years in-trial) and classified into: "no depression," "pre-existing" and "incident" depression groups based on either being "diagnosed with depressive disorders" and/or "treated with an anti-depressant drug" at baseline or during in-trial period. Further, we redefined "depression" restricted to presence of both conditions for sensitivity analyses. For the current study, end-points were all-cause and any cardiovascular mortality.

RESULTS

313 (5%) participants had pre-existing depression and a further 916 (15%) participants developed depression during the trial period (incidence 4% per annum). Increased (hazard-ratio, 95% confidence-interval) all-cause mortality was observed among those with either pre-existing (1.23, 1.01-1.50; p = 0.03) or incident (1.26, 1.12-1.41; p < 0.001) depression compared to those without. For cardiovascular mortality, a 24% increased risk (1.24, 1.05-1.47; p = 0.01) was observed among those with incident depression. The sensitivity analyses, using the restricted depression definition showed similar associations. Incident depression was associated with being female, aged ≥75 years, being an active smoker at study entry, and developing new diabetes during the study period.

CONCLUSIONS

This elderly cohort had a high incidence of depression irrespective of their randomised antihypertensive regimen. Both pre-existing and incident depression were associated with increased mortality.

Risk of high blood pressure associated with objective insomnia and self-reported insomnia complaints in major depression: A study on 703 individuals

BACKGROUND

Since few studies have investigated the risk of high blood pressure associated with objective insomnia and self-reported insomnia complaints in major depression, the aim of this study was to examine this risk in a large sample of individuals with major depression.

METHODS

Data from 703 individuals with major depression recruited from the research database of the sleep laboratory of the Erasme Hospital were analysed. High blood pressure status was defined by the presence of one of the following: self-reports at interview of either a physician-diagnosis or taking antihypertensive medication; or an average systolic blood pressure ≥140 mmHg or an average diastolic blood pressure ≥90 mmHg during at least two medical examinations. Logistic regression analyses were conducted to examine the risk of high blood pressure associated with objective insomnia and self-reported insomnia complaints in major depression.

RESULTS

After adjustment for major confounding factors associated with high blood pressure, multivariate logistic regression analysis revealed that severe objective insomnia, low complaints of repeated nighttime awakenings or early morning awakening, and intermediate or low self-reported insomnia complaints were significant risk factors of high blood pressure in major depression.

CONCLUSION

In major depression, severe objective insomnia and lower self-reported insomnia complaints are associated with higher risk of high blood pressure, which justifies a better management of objective insomnia and a better assessment of insomnia complaints in this particular subpopulation to avoid the negative consequences related to the co-occurrence of high blood pressure and major depression. Abbreviations: AHI, Apnea-Hypopnea Index; BDI, Beck Depression Inventory; BMI, Body Mass Index; DSM IV-TR, Diagnostic and Statistical Manual of Mental Disorders fourth edition - Text Revision; ESS, Epworth Sleepiness scale; ISI, Insomnia Severity Index; HBP, High Blood Pressure; OSA, Obstructive Sleep Apnea Syndrome; REM, rapid eye movement sleep.

Sex differences and the prognosis of depressive and nondepressive patients with cardiovascular risk factors: the Japan Morning Surge-Home Blood Pressure (J-HOP) study

Depression is associated with mortality in patients with cardiovascular risk factors. The frequency and severity of depression and the association between depression and cardiovascular events have sex-specific and ethnic differences. We conducted this study to evaluate the sex-specific difference in the association between depression and cardiovascular prognosis in patients with cardiovascular risk factors. We enrolled 4025 patients (64.7 ± 10.9 years, 53% women, 47% men) with cardiovascular risk factors in the Japan Morning Surge-Home Blood Pressure study. Depressive symptoms were assessed using the Beck Depression Inventory (BDI). The follow-up period was 47 ± 24 months. The primary end points were all-cause mortality and nonfatal cardiovascular events. The BDI scores and the prevalence of depression were significantly higher in women than in men. When a BDI score of 16 was the cutoff, the primary end points in the depression group (n = 217) were significantly higher than those in the nondepression group (n = 1677) among men (adjusted hazard ratio 1.76, 95% confidence interval: 1.17, 2.64; P = 0.007). In women, the primary end points in the depression and nondepression groups were similar when BDI scores of 16, 14, and 10 were the cutoffs. In conclusion, depression defined by a BDI score ≥16 was associated with cardiovascular events in men with cardiovascular risk factors.

Relationships between the neighborhood environment and depression in older adults: a systematic review and meta-analysis

ABSTRACTBackground:While depression is a growing public health issue, the percentage of individuals with depression receiving treatment is low. Physical and social attributes of the neighborhood may influence the level of depressive symptoms and the prevalence of depression in older adults.

METHODS

This review systematically examined the literature on neighborhood environmental correlates of depression in older adults. Findings were analyzed according to three depression outcomes: depressive symptoms, possible depression, and clinical depression. Based on their description in the article, environmental variables were assigned to one of 25 categories. The strength of evidence was statistically quantified using a meta-analytical approach with articles weighted for sample size and study quality. Findings were summarized by the number of positive, negative, and statistically non-significant associations by each combination of environmental attribute - depression outcome and by combining all depression outcomes.

RESULTS

Seventy-three articles met the selection criteria. For all depression outcomes combined, 12 of the 25 environmental attribute categories were considered to be sufficiently studied. Three of these, neighborhood socio-economic status, collective efficacy, and personal/crime-related safety were negatively associated with all depression outcomes combined. Moderating effects on associations were sparsely investigated, with 52 articles not examining any. Attributes of the physical neighborhood environment have been understudied.

CONCLUSION

This review provides support for the potential influence of some neighborhood attributes on population levels of depression. However, further research is needed to adequately examine physical attributes associated with depression and moderators of both social and physical neighborhood environment attribute - depression outcome associations.

[Antihypertensive therapy in the elderly]

Arterial hypertension is the most common modifiable risk factor for cerebrovascular and cardiovascular morbidity and mortality in old age. The prevention of cognitive brain disorders is also a therapeutic goal of long-term treatment of hypertension. Older patients also have a higher risk of developing cardiovascular diseases and therefore benefit from a relatively moderate reduction in blood pressure. With respect to the high prevalence of hypertension in old age and the increasing incidence with time, the therapy of hypertension is becoming increasingly more important to achieve an improved prognosis for patients along with a reduction of costs. The accurate blood pressure measurement for elderly patients includes repeated measurements while standing and sitting. Additionally, the measurements should also be conducted by the patient or by a family member. The most accurate method for assessing the daily blood pressure level, e.g. practice hypertension, non-dipping and intermittent hypertension, is the 24-h blood pressure measurement by ambulatory blood pressure monitoring (ABPM). General measures and lifestyle interventions are effective for reducing blood pressure of elderly patients with hypertension and a low salt diet is scientifically proven to be superior. The same drugs used for young people are also recommended for older patients and most give preference to diuretics, renin-angiotensin-aldosterone system (RAAS) inhibitors and calcium antagonists. The target blood pressure in elderly patients is repeatedly the focus of scientific discussions. The current recommendations are presented in the text and the characteristics which must be particularly considered in the therapy of elderly patients are presented in detail.

Angiotensin-I Converting Enzyme (ACE) Inhibitory and Anti-Oxidant Activities of Sea Cucumber (Actinopyga lecanora) Hydrolysates

In recent years, food protein-derived hydrolysates have received considerable attention because of their numerous health benefits. Amongst the hydrolysates, those with anti-hypertensive and anti-oxidative activities are receiving special attention as both activities can play significant roles in preventing cardiovascular diseases. The present study investigated the angiotensin-I converting enzyme (ACE) inhibitory and anti-oxidative activities of Actinopyga lecanora (A. lecanora) hydrolysates, which had been prepared by alcalase, papain, bromelain, flavourzyme, pepsin, and trypsin under their optimum conditions. The alcalase hydrolysate showed the highest ACE inhibitory activity (69.8%) after 8 h of hydrolysis while the highest anti-oxidative activities measured by 2,2-diphenyl 1-1-picrylhydrazyl radical scavenging (DPPH) (56.00%) and ferrous ion-chelating (FIC) (59.00%) methods were exhibited after 24 h and 8 h of hydrolysis, respectively. The ACE-inhibitory and anti-oxidative activities displayed dose-dependent trends, and increased with increasing protein hydrolysate concentrations. Moreover, strong positive correlations between angiotensin-I converting enzyme (ACE) inhibitory and anti-oxidative activities were also observed. This study indicates that A. lecanora hydrolysate can be exploited as a source of functional food owing to its anti-oxidant as well as anti-hypertension functions.

The older the better: are elderly study participants more non-representative? A cross-sectional analysis of clinical trial and observational study samples

OBJECTIVE

Study participants can differ from the target population they are taken to represent. We sought to investigate whether older age magnifies such differences, examining age-trends, among study participants, in self-rated level of activity compared to others of the same age.

DESIGN

Cross-sectional examination of the relation of participant age to reported 'relative activity' (ie, compared to others of the same age), a bidirectionally correlated proxy for relative vitality, in exemplars of randomised and observational studies.

SETTING

University of California, San Diego (UCSD) PARTICIPANTS: 2404 adults aged 40-79 including employees of UCSD, and their partners (San Diego Population Study, observational study). 1016 adults (aged 20-85) not on lipid medications and without known heart disease, diabetes, cancer or HIV (UCSD Statin Study, randomised trial).

MEASUREMENTS

Self-rated activity relative to others' age, 5-point Likert Scale, was evaluated by age decade, and related via correlation and regression to a suite of health-relevant subjective and objective outcomes.

RESULTS

Successively older participants reported successively greater activity relative to others of their age (greater departure from the norm for their age), p<0.001 in both studies. Relative activity significantly predicted (in regression adjusted for age) actual activity (times/week exercised), and numerous self-rated and objective health-predictors. These included general self-rated health, CES-D (depression score), sleep, tiredness, energy; body mass index, waist circumference, serum glucose, high-density lipoprotein-cholesterol, triglycerides and white cell count. Indeed, some health-predictor associations with age in participants were 'paradoxical,' consistent with greater apparent health in older age-for study participants.

CONCLUSIONS

Study participants may not be representative of the population they are intended to reflect. Our results suggest that departures from representativeness may be amplified with increasing age. Consequently, the older the age, the greater the disparity may be between what is recommended based on 'evidence, ' and what is best for the patient.

TRIAL REGISTRATION

UCSD Statin Study-Clinicaltrials.gov # NCT00330980 (http://ClinicalTrials.gov).