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Original Investigation |

Prevalence, Clinical Correlates, and Treatment of Hypertension in Elderly Nursing Home Residents FREE

Giovanni Gambassi, MD; Kate Lapane, PhD; Antonio Sgadari, MD; Francesco Landi, MD; Pierugo Carbonin, MD; Anne Hume, PharmD; Lewis Lipsitz, MD; Vincent Mor, PhD; Roberto Bernabei, MD ; for the SAGE (Systematic Assessment of Geriatric Drug Use via Epidemiology) Study Group
[+] Author Affiliations

From the Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy (Drs Gambassi, Sgadari, Landi, Carbonin, and Bernabei); Department of Community Health (Drs Gambassi, Lapane, and Mor) and Center for Gerontology and Health Care Research (Drs Gambassi, Lapane, and Mor), Brown University, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston (Dr Hume); and Hebrew Rehabilitation Center for the Aged, Harvard Medical School, Boston, Mass (Dr Lipsitz).


Arch Intern Med. 1998;158(21):2377-2385. doi:10.1001/archinte.158.21.2377.
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Background  Hypertension is prevalent in the elderly, but an information gap remains regarding the old, frail, individuals with complex conditions living in long-term care.

Objective  To analyze the patterns of antihypertensive drug therapy among elderly patients living in nursing homes to elucidate their conformity with consensus guidelines.

Subjects and Methods  We used a long-term care database that merged sociodemographic, functional, clinical, and treatment information on nearly 300000 patients admitted to the facilities of 5 US states between 1992 and 1994.

Results  Hypertension was diagnosed in 80206 patients (mean age, 82.7±7.8 years). The prevalence was higher among women and among blacks. About one fourth of patients had 6 or more comorbid conditions; 26%, 22%, and 29% had concomitant diagnoses of coronary heart disease, congestive heart failure, and cerebrovascular disease, respectively. Seventy percent of patients were treated pharmacologically. Calcium channel blockers were the most common agents (26%), followed by diuretics (25%), angiotensin-converting enzyme inhibitors (22%), and β-blockers (8%). The relative use of these drugs changed according to the presence of other cardiovascular conditions. Adjusting for potential confounders, the relative odds of receiving antihypertensive therapy were significantly decreased for the oldest subjects (≥85 years old: odds ratio, 0.85; 95% confidence interval, 0.81-0.89) and those with marked impairment of physical (odds ratio, 0.77; 95% confidence interval, 0.73-0.81) and cognitive (odds ratio, 0.67; 95% confidence interval, 0.64-0.70) function.

Conclusions  Among very old, frail hypertensive patients living in nursing homes, the pattern of treatment seems not to follow recommended guidelines; age, functional status, and comorbidity appear to be important determinants of treatment choice.

Figures in this Article

HYPERTENSION IS one of the most frequent conditions of older people13 and is an important risk factor for cardiovascular and cerebrovascular disease.47 Recent data support the notion that the absolute benefits of pharmacological treatment are even more pronounced in the elderly, both in men and in women.8,9 Randomized controlled trials have shown that diuretics, and possibly β-blockers and some calcium channel blockers, reduce morbidity and improve survival of older, but otherwise healthy, hypertensive patients.1013 Accordingly, the Joint National Committee has repeatedly recommended these drugs as the preferred choice.14,15

Regardless, several calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors have become widely prescribed, especially among elderly patients.1619 ACE inhibitors are effective in reducing blood pressure, but their effect on morbidity or mortality among hypertensive patients is still unknown.4 In the past 2 years, observational studies have questioned the widespread use of calcium channel blockers because of increased morbidity and mortality in selected patients with coronary heart disease,20,21 but also in adult22 and elderly23 hypertensive patients. The Systolic Hypertension in Europe Trial is the only trial that has shown a clear benefit conferred by a calcium channel blocker, but the study enrolled exclusively elderly patients with isolated systolic hypertension.13 Yet, no other data from controlled trials are available in this diverse population.

People older than 65 years, despite representing 15% of the US population and using one third of all medications, remain underrepresented in randomized clinical trials.24,25 Recently this limitation has been recognized, and all of the studies currently in progress concentrate on older hypertensive patients, some with no upper limit on age.26 However, randomized trials in the elderly can pose serious challenges, and even when targeted to these patients, only the relatively healthier population is included, producing results of limited generalizability.11 In general, the ideal patient for a trial little resembles the clinically complex, frail older patient for whom most of the drugs are prescribed. Such difference is amplified for patients who reside in nursing homes; typically they are the oldest old, are often cognitively and physically impaired, usually have multiple comorbid conditions, and take numerous medications.27 Little is known about hypertensive patients who reside in long-term care facilities, despite the increasing importance of this health sector.28,29

The objective of our study was to investigate to what extent antihypertensive drug prescribing patterns conform to consensus guidelines, to evaluate the impact of age and comorbidity, and to identify the independent predictors of receiving pharmacological treatment for hypertension among elderly patients living in nursing homes.

Since 1991, all US nursing homes have been required to use a uniform, comprehensive assessment tool known as the Resident Assessment Instrument (RAI) with its Minimum Data Set (MDS),30 establishing a national, long-term care database. The present study used data from the Health Care Financing Administration's Multi-State, Case-Mix and Quality Demonstration Project involving all 1492 Medicare- and Medicaid-certified nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota. We have merged 3 databases: (1) a computerized, longitudinal MDS data set on nearly 300000 patients residing in, or admitted to, a nursing home in any of the 5 states during the period from January 1, 1992, through December 31, 1994; (2) a longitudinal file containing data on all drugs received by each patient; and (3) the Medicare enrollment files and Medicare Provider Analysis and Review database, which contains information on all persons covered by Medicare Part A. The resulting database (Systematic Assessment of Geriatric Drug Use via Epidemiology [SAGE]) has been described in detail elsewhere,3133 and it is briefly summarized herein.

SAGE DATABASE

The MDS includes sociodemographic information, numerous clinical items ranging from the degree of physical dependence to cognitive functioning, and all active clinical diagnoses.30,31 The MDS also includes an extensive array of signs, symptoms, syndromes, treatments, and indicators that describe each resident's behavior and mood.30,31 A variety of multi-item, summary scales are embedded in the MDS to examine the performance on Activities of Daily Living, cognition, mood status, behavioral problems, social engagement, communication, mobility, and urinary continence.32,33

In addition to MDS data, staff recorded up to 18 different drugs received by each resident in the 7 days preceding the assessment. Information on the resident's drug therapy included brand or generic name, dosage, route and frequency of administration, and whether it was given on a standing or as-needed order.32 Drugs were coded according to the National Drug Code system. We used the Master Drug Data Base (MediSpan Inc, Indianapolis, Ind) to translate National Drug Codes into therapeutic classes and subclasses.33

POPULATION SAMPLE

From an initial population of 296379 unique individuals (January 1, 1992, through December 31, 1994), we excluded patients younger than 65 years (n=25506) and those in a comatose state (n=725). We then identified 80206 patients based on the presence of a diagnosis of hypertension at their initial MDS assessment. Staff physicians coded a diagnosis of hypertension by means of information obtained from the medical record, including the physical examination of the resident, medication and other treatment orders, and hospital discharge documentation (if any).34 In interrater trials, the κ coefficient for the diagnosis of hypertension was found to be excellent (0.80).35 In addition, a diagnosis of hypertension on the MDS record could be confirmed through the Medicare hospital discharge claims in more than 83% of cases with a hospitalization shortly preceding the MDS.33

ANALYTIC APPROACH

We conducted a cross-sectional study based on the initial MDS assessment of the 80206 hypertensive patients. We evaluated age differences by stratifying the sample into 3 age categories: 65 to 74 years (n=13285), 75 to 84 years (n=31707), and 85 years or older (n=35214). Performance in physical function was expressed with a 5-item, 6-level Activities of Daily Living Scale, and cognition was measured with a 6-item, 7-level Cognitive Performance Scale, both of which have been previously validated.36,37

Antihypertensive medications were classified by the following MediSpan classification codes: 33.10, β-blockers, nonselective; 33.20, β-blockers, selective; 34.00, calcium channel blockers (subsequently distinguished as dihydropyridines, diphenylalkylamine, or benzothiazepine); 36.10, ACE inhibitors; 36.20, adrenolytic agents (ie, methyldopa, clonidine, reserpine, guanabenz); 36.30, α-blockers; 36.40, hydralazine; 37.20, loop diuretics; 37.50, potassium-sparing diuretics; and 37.60, thiazides. Nitrates (32.10) were also computed.

To evaluate age trends, we performed Mantel-Haenszel χ2 tests.38 We evaluated predictors of pharmacological treatment of hypertension by developing a multiple logistic regression model. Based on crude analyses of the association between pharmacological treatment and various independent variables, including sociodemographic variables, measures of physical and cognitive functioning, and indexes of comorbid conditions, we identified potential predictors for the model. Before constructing the model, we evaluated (and ruled out) multicollinearity. From the final model, we derived odds ratios and corresponding 95% confidence intervals. All analyses were performed with SAS software (version 6.12, SAS Institute, Cary, NC).

PREVALENCE OF HYPERTENSION

Overall, nearly 32% of the nursing home residents (mean age, 82.7±7.8 years; range, 65-115 years) had a diagnosis of hypertension. The prevalence of hypertension was higher among women (33%) than men (27%) and among African Americans (43%) and other minorities (34%) than among whites (30%). As age increased, the prevalence of hypertension declined slightly (35% in the 65- to 74-year-old group vs 33% and 30% in the 75- to 84-year-old and ≥85-year-old groups, respectively), which is accounted for by the decline among men and African Americans. Prevalence of hypertension among women and white patients did not differ by age.

SAMPLE CHARACTERISTICS

Table 1 summarizes the principal sociodemographic characteristics and several functional variables of hypertensive patients. The proportion of women and white patients increased with age. Overall, two thirds of patients were admitted from an acute care hospital, and 60% of them stayed in the nursing home for less than 6 months. As many as 30% of patients had a body mass index less than 20 kg/m2. While 16% of patients overall required no, or minimal, assistance performing basic daily activities, 40% showed severe impairment. No major age-related differences were observed. On the other hand, more than 40% of patients (39%-48% by age group) had only minimally impaired cognitive function. Overall, 46% of patients had urinary incontinence and one third had experienced at least 1 fall in the preceding 6 months.

Table Graphic Jump LocationTable 1. Principal Characteristics of Hypertensive Patients*
COMORBIDITY

Table 2 shows that two thirds of patients had more than 3 comorbid medical conditions in addition to hypertension, and 25% had 6 or more. Increased age was associated with a significantly greater number of comorbid conditions. Twenty-six percent, 22%, and 29% of patients had a concomitant diagnosis of coronary heart disease (CHD), congestive heart failure (CHF), or cerebrovascular disease, respectively. While the proportion of hypertensive patients with coexisting CHD and CHF increased by 50% or more in the group aged 85 years or older as compared with the 65- to 74-year-old group, a significant decline in the proportion of patients affected by cerebrovascular conditions was evident. There was a steady increase in the proportion of patients diagnosed as having dementia (23% in the 65- to 74-year-old group as compared with 35% in the ≥85-year-old group; P<.001). Clinical conditions known to decrease survival, such as diabetes mellitus, chronic obstructive pulmonary disease, and renal failure, were less frequent in the older age strata. Across age groups, 8% of hypertensive patients had a diagnosis of cancer.

Table Graphic Jump LocationTable 2. Principal Comorbid Clinical Conditions Among Hypertensive Patients*
ANTIHYPERTENSIVE TREATMENT

Nearly 60% of patients received more than 5 medications daily, and as many as 23% patients aged 65 to 74 years received 11 or more. In contrast to the trend observed with most clinical diagnoses, increased age was associated with reduced drug use. Table 3 summarizes the overall use of antihypertensive agents. The proportion of hypertensive patients receiving at least 1 antihypertensive medication (70%) was similar in each age category. Of the patients receiving antihypertensive medications, 54% received a single agent, while less than 20% received a combination of 3 or more antihypertensive agents.

Table Graphic Jump LocationTable 3. Overall Use of Antihypertensive Agents

Calcium channel blockers were the most commonly used therapeutic agents (26% of patients overall), followed by diuretics (25%) and ACE inhibitors (22%); β-blockers were used by less than 10% of patients. The use of adrenolytic agents, α-blockers, and vasodilators such as hydralazine was relatively infrequent. Significant, and opposite in some instances, age-related trends were observed for virtually all antihypertensive agents. The use of antiadrenergic agents showed a decline with increasing age; only 7% of patients aged 85 years or older used β-blockers as compared with 11% in the younger group (P<.001). The proportion of patients treated with calcium channel blockers decreased from 30% in the 65-to 74-year-old group to 27% and 22% in the groups aged 75 to 84 years and 85 years or older, respectively (P<.001 for trend). This difference is explained by a parallel decrease in the use of the dihydropyridine calcium channel blockers. In contrast, the overall use of diuretics increased significantly among older hypertensive patients. In patients aged 85 years or older, diuretics were used more frequently than any other agent (29% of patients vs 22% of patients receiving a calcium channel blocker). Minor age-related differences were observed in the use of ACE inhibitors.

Calcium channel blockers were more likely to be prescribed as single agents than were diuretics, ACE inhibitors, and β-blockers. Among patients using a single antihypertensive agent (n=30383), calcium channel blockers were the preferred option (35% of patients), followed by diuretics (29%) and ACE inhibitors (26%). Among patients receiving 2 antihypertensive drugs (n=16859), diuretics were used more frequently than any other class (34% of patients compared with 29% and 26% receiving an ACE inhibitor or a calcium channel blocker, respectively).

Figure 1 illustrates the proportion of patients treated with antihypertensive medications as a function of the presence of relevant cardiovascular comorbidities. As compared with patients with hypertension alone (n=17297), the use of diuretics and ACE inhibitors increased among hypertensive patients with CHD (n=20887), while it doubled in those with a concomitant CHF diagnosis (from 21% to 44%, and from 18% to 35% of patients in the case of diuretics and ACE inhibitors, respectively). In contrast, the proportion of patients treated with a calcium channel blocker was slightly decreased only if concomitant with a CHF diagnosis (26% vs 23%; P<.005). Similar changes were observed for the use of β-blockers. As a result, calcium channel blockers remained the most commonly used antihypertensive agents among patients with hypertension alone or in association with CHD, while the use of diuretics exceeded that of any other agent when CHF coexisted with hypertension.

Place holder to copy figure label and caption

Percentages of patients with hypertension (HTN) treated with diuretics, β-blockers (BB), angiotensin-converting enzyme inhibitors (ACE-I), or calcium channel blockers (CCB), according to the absence or presence of concurrent cardiovascular comorbid conditions, such as coronary heart disease (CHD) and congestive heart failure (CHF).

Graphic Jump Location

The pattern of antihypertensive drug use varied consistently with age whether hypertension was the only diagnosis or was associated with CHD. There was a sustained, age-related reduction in the proportion of patients receiving any of the medications, especially β-blockers (reduced by more than 40%).The only exception was diuretics, which exhibited a sharp increase (on average a 44% increase when the 2 extreme age groups were compared). Similar changes were observed when hypertension and CHF coexisted, although to a lesser extent. Diuretic use was prevalent in any instance (42% of patients overall) and was only slightly higher among patients aged 85 years or older.

The independent predictors of receiving at least 1 antihypertensive medication are listed in Table 4. The relative odds of receiving therapy were significantly decreased for older subjects and men. The presence of a concurrent cardiovascular condition and already being a recipient of a greater number of medications were both independently associated with an increased likelihood of receiving antihypertensive therapy. On the other hand, severe physical and cognitive impairment were inversely related to antihypertensive pharmacological treatment.

Table Graphic Jump LocationTable 4. Factors Associated With Receiving at Least 1 Antihypertensive Agent*

Our study documents that hypertension is a common clinical condition among very old residents of long-term care facilities, especially among women and African Americans and other minority groups. The overall picture is that of frail patients with complex medical conditions who have a burden of cardiovascular and neurologic comorbid conditions. Polypharmacy is a distinguishing feature of these patients; 70% receive at least 1 antihypertensive drug, most commonly a calcium channel blocker, followed by diuretics and then ACE inhibitors.

Numerous large, placebo-controlled, randomized clinical trials have investigated the benefit conferred by treatment of combined systolic-diastolic or isolated systolic hypertension in the elderly. In the European Working Party on High Blood Pressure in the Elderly trial,40 patients treated with a thiazide diuretic experienced a statistically significant reduction (approximately 39%) in all cumulative cardiovascular events relative to patients taking placebo. The Swedish Trial in Old Patients with Hypertension41 was interrupted prematurely because, after an average follow-up of 2 years, patients taking a thiazide diuretic and/or a β-blocker experienced a 40% reduction in cumulative cardiovascular events, 47% reduction in all strokes (fatal and nonfatal), and a 43% reduction in total mortality relative to placebo. About two thirds of patients were receiving both medications, and results for the individual drug treatment arms were not reported, although diuretic appeared to be significantly more effective in reducing blood pressure. In the Medical Research Council trial,42 patients receiving active treatment took either a thiazide diuretic or atenolol. After an average follow-up of 5.8 years, in the diuretic arm there was a 31%, 44%, and 35% reduction in the incidence of stroke, coronary events, and all cumulative cardiovascular events, respectively, whereas the β-blocker group showed no difference relative to placebo. Two trials, the Systolic Hypertension in the Elderly Program and the Systolic Hypertension in Europe trial, have focused on patients with isolated systolic hypertension. The Systolic Hypertension in the Elderly Program12 demonstrated that the incidence of all cumulative cardiovascular events was reduced by more than 40% with a thiazide diuretic treatment, and the incidence of the other prespecified end points was also substantially lower. The Systolic Hypertension in Europe trial,13 the only trial to investigate antihypertensive medications other than diuretics or β-blockers, has shown that the dihydropyridine calcium channel blocker nitrendipine (with the possible addition of an ACE inhibitor and/or a diuretic) decreased overall stroke rate by 42% and the incidence of all cardiac events by approximately 30%.

Thus, randomized clinical trials have demonstrated that only the use of diuretics, and possibly of β-blockers and some calcium channel blockers, can reduce the incidence of CHF, as well as stroke, coronary disease, and overall cardiovascular mortality.813 While newer agents (different calcium channel blockers and ACE inhibitors) are effective in reducing blood pressure and ameliorating some surrogate end points, and while they may also be better tolerated,43,44 there is no conclusive evidence of an effect on morbidity and mortality.45,46 According to the evidence available, the Joint National Committee and the National High Blood Pressure Education Program Working Group have continued to recommend diuretics and β-blockers as the preferred first-line agents.14,15

The patterns of drug use that we have documented suggest that these recommendations have little, if at all, informed the practice of nursing home physicians. These findings are in agreement with several recent reports describing the progressive decline of diuretic use and the parallel increase of use of ACE inhibitors and calcium channel blockers that have occurred in other settings.1619 Several reasons can possibly explain the apparent nonadherence to widely accepted recommendations. Some authors have suggested that clinicians may be disappointed with the results of completed clinical trials in which blood pressure reduction has yielded less benefit on coronary artery disease outcomes than expected.16 Such consideration implies a widespread dissemination of the recommendations; although possible, this has been shown not to occur in different settings.16,47,48 Instead, it is likely that the effectiveness of pharmaceutical promotion practices relative to the guidelines or the attractiveness of using new therapies has had the greatest impact.49,50 Alternatively, the present findings may reflect appropriate prescribing by an enlightened physician facing the difficult applicability of the guidelines to the frail, very old nursing home resident with multiple comorbid conditions and concomitant, complex pharmacological regimens.

Indeed, the results of the published trials are hardly applicable to the treatment of all older hypertensive patients, and apparently less so to institutionalized individuals.11,51 In seeking internal validity, randomized controlled trials have shown efficacy of treatment for only an average, "eligible" patient, and not for pertinent subgroups characterized by such cogent clinical features as severity of symptoms, illness, comorbidity, and other clinical nuances. Generally, the patients enrolled were healthy cohorts of younger people living in the community.11 For example, the Systolic Hypertension in the Elderly Program trial52 included only 2% demented, 10% depressed, and 7% physically disabled patients, whereas in an age-matched general population these conditions have been reported to occur in 6%, 23%, and 19% of people, respectively. These estimates are far lower than those found among the oldest old, frail residents of long-term care facilities, which were specifically excluded by any trial. For example, in the present study, 29% to 43% of patients were affected by dementia and, indirectly confirming the validity of the diagnosis of hypertension, the vascular type was far more common. This circumstance merits careful consideration, because, although there is evidence that antihypertensive medications commonly used do not adversely affect cognition,5355 overall the issue remains controversial.56 The relatively high prevalence of diabetes mellitus and the additional presence of chronic obstructive pulmonary disease might have justified a reduced use of diuretics and β-blockers, which have been shown to exacerbate insulin resistance, adversely affect plasma lipid levels, and worsen symptoms of obstructive pulmonary disease.15 Conversely, in a more empirical way, ACE inhibitors and calcium channel blockers could have had better safety profiles in these conditions. Finally, the high prevalence of urinary incontinence, frequent falls, and depression may have justified the use of certain medications in favor of others.

We found that about 30% of hypertensive patients were not receiving any traditionally known antihypertensive agent, and this is consistent with previous reports.5760 Even after adjusting for many relevant variables, increased age was strongly associated with an increased likelihood of not being treated, whereas high-risk individuals (those with multiple cardiovascular comorbidities) seemed more likely to receive a pharmacological treatment. Because of the limitations of our data, no inferences can be made regarding quality or appropriateness of treatment. However, it is completely unknown whether the risks of therapy may outweigh the benefits among severely impaired patients.

Also, the possibility that the benefit of antihypertensive treatment does not extend to patients beyond a certain age threshold needs to be carefully considered. In the randomized controlled trials of antihypertensive drug treatment in the elderly, age at recruitment ranged from 60 to 97 years. In the European Working Party on High Blood Pressure in the Elderly trial,40 the reduction in cardiovascular mortality was progressively lessened in the oldest patients, especially beyond 80 years. There was similar evidence in the Swedish Trial in Old Patients with Hypertension.41 Older patients randomized to receive active treatment, compared with placebo, experienced less reduction of stroke, myocardial infarction, or other cardiovascular death than younger patients. A new report from the Systolic Hypertension in Europe Trial reinforces the warning that the effect of antihypertensive drug treatment may be attenuated in very old patients.61 Above 75 years of age there was no treatment benefit in terms of total and cardiovascular mortality. Nonetheless, the authors documented that stroke and cardiac end points may be still prevented, at least until 78 to 80 years of age (eg, when the upper 95% confidence limit included unity). Yet, these do not represent conclusive evidence, because trials differed in their treatment regimens and outcome definitions, and may have included too few patients older than 80 years to permit meaningful interpretation of the risk in this age stratum. In this regard, in the Systolic Hypertension in the Elderly Program, which included 650 patients aged 80 years or older, the reduction in the risk of stroke was completely preserved in this cohort. The remaining uncertainties could be resolved by the results of the Hypertension in the Very Elderly Trial62 currently ongoing.

Our study has several limitations. First, it included exclusively institutionalized individuals, and as such the findings are not necessarily generalizable to the majority of the oldest old hypertensive patients living in the community. It is difficult to determine whether cross-sectional findings related to age may be attributed to aging or to age-related selection bias, such as a survivor effect. There is potential for misclassification of the diagnosis of hypertension and for the use of "antihypertensive" medications for indications other than hypertension. We lack blood pressure measurements and we are unable to assess the severity and control of hypertension. However, several considerations lead us to believe that our sample represents "real" hypertensive patients, and the bias, if any, is conservative. First, the prevalence estimates we report are similar to those documented by the recent national nursing home survey63 and by other authors examining patients who live in long-term care facilities, with clinical examination,64 chart review,65 or analysis of data collected with MDS.66 In addition, the age- and gender-related trends are consistent with several National Health Interview and Examination Surveys in noninstitutionalized people,6770 but also with reports on residents of long-term care facilities.67,71 Second, to ensure quality of care, the nurses in our study had to measure blood pressure before administering an antihypertensive medication, and drug treatment, regardless of specific class, was stable over extended periods (G.G., unpublished observation, 1998). Third, a diagnosis of hypertension was found consistently across all MDS assessments if the patients had such a condition collected. Fourth, the accuracy, reliability, and validity of the diagnosis of hypertension has already been shown to be excellent.33,35 In addition, in our study as well in others,72 few patients (approximately 9%) were using an "antihypertensive" drug for an indication other than hypertension or any plausible cardiovascular condition.

In conclusion, our study shows that current prescription patterns do not concur with widely approved guidelines for the pharmacological treatment of hypertension. Future studies will have to address the precise reasons for this divergence, but age, functional status, and comorbidity appear to be important determinants of treatment choice. Although this is not a phenomenon restricted to the nursing home, the risk-benefit ratio of any antihypertensive treatment remains undefined in the typical nursing home patient.

Accepted for publication March 12, 1998.

Steering Committee: Roberto Bernabei, MD, Università Cattolica del Sacro Cuore, Rome, Italy; Constantine Gatsonis, PhD, Brown University, Providence, RI; Lewis Lipsitz, MD, Harvard Medical School, Boston, Mass; Vincent Mor, PhD, Brown University. Coordination: Giovanni Gambassi, MD, Università Cattolica del Sacro Cuore and Brown University; Kate Lapane, PhD, Brown University. Writing Panel: Daniel Forman, MD, Brown University; David Gifford, MD, Brown University; Francesco Landi, MD, Università Cattolica del Sacro Cuore; Antonio Sgadari, MD, Università Cattolica del Sacro Cuore. Data Management: Jeffrey Hiris, MS, Brown University; Chris Brostrup-Jensen, BA, Brown University; Sharon Gonzales, MSPH, Brown University. Biostatistics: Constantine Gatsonis, PhD, Brown University; Joseph Hogan, PhD, Brown University; Orna Intrator, PhD, Brown University. Participants: Marilyn Barbour, PharmD, University of Rhode Island, Kingston; Katherine Berg, PhD, Brown University; Anne Hume, PharmD, University of Rhode Island; Paul Larratt, PhD, University of Rhode Island; Knight Steel, MD, Hackensack University Medical Center, Hackensack, NJ.

Reprints: Giovanni Gambassi, MD, Center for Gerontology and Health Care Research, Brown University, Box G-B213, Providence, RI 02912 (e-mail: giovanni_gambassi@brown.edu).

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Pahor  MGuralnik  JMCorti  MCFoley  JDCarbonin  PHavlik  RJ Long-term survival and use of antihypertensive medication in older persons. J Am Geriatr Soc. 1995;431191- 1197
Avorn  J Medication use and the elderly: current status and opportunities. Health Aff. Spring1995;276- 286
Gurwitz  JHCol  NFAvorn  J The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA. 1992;2681417- 1422
Link to Article
Elliott  WJ ALLHAT: the largest and most important clinical trial in hypertension ever done in the USA. Am J Hypertens. 1996;9409- 411
Link to Article
Fried  TRMor  V Frailty and hospitalization of long-term stay nursing home residents. J Am Geriatr Soc. 1997;45265- 269
Frohlich  ED Hypertension in the elderly: only the end of the beginning. Hypertension. 1994;23286- 287
Link to Article
Haydar  ZRRywick  TFleg  JL Isolated systolic hypertension in the nursing home. Nurs Home Med. 1997;541- 49
Morris  JNHawes  CFries  BE  et al.  Designing the national resident assessment instrument for nursing homes. Gerontologist. 1990;30293- 297
Link to Article
Bernabei  RGambassi  GMor  V The SAGE database: introducing functional outcomes in geriatric pharmaco-epidemiology. J Am Geriatr Soc. 1998;46251- 252
Bernabei  RGambassi  GLapane  K  et al.  Principal characteristics of the SAGE database: a new resource for research on outcomes in long-term care. J Gerontol. In press.
Gambassi  GLandi  FPeng  L  et al.  Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. Med Care. 1998;36167- 179
Link to Article
Not Available, Minimum Data Set Plus Training Manual.  Natick, Mass Eliot Press1991;
Hawes  CMorris  JNPhillips  CDMor  VFries  BENonemaker  S Reliability estimates for the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). Gerontologist. 1995;35172- 178
Link to Article
Morris  JNFries  BEMehr  DR  et al.  MDS Cognitive Performance Scale. J Gerontol. 1994;49M174- M182
Link to Article
Mor  VBranco  KFleishman  J  et al.  The structure of social engagement among nursing home residents. J Gerontol B Psychol Sci Soc Sci. 1995;50P1- P8
Link to Article
Mantel  N Chi-square tests with one degree of freedom: extension of the Mantel-Haenszel procedure. J Am Stat Assoc. 1963;58690- 700
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Amery  ABirkenhager  WBrixko  P  et al.  Efficay of antihypertensive drug treatment according to age, sex, blood pressure, and previous cardiovascular disease in patients over the age of 60. Lancet. 1986;2589- 592
Link to Article
Dahlof  BLindholm  LHHansson  LSchersten  BEkbom  TWester  P-O Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet. 1991;3381281- 1285
Link to Article
MRC Working Party, Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ. 1992;304405- 412
Link to Article
Monane  MBohn  RLGurwitz  JHGlynn  RJLevin  RAvorn  J The effects of initial drug choice and comorbidity on antihypertensive therapy compliance: results from a population-based study in the elderly. Am J Hypertens. 1997;10697- 704
Link to Article
Philipp  TAnlauf  MDistler  AHolzgreve  HMichaelis  JWellek  S Randomised, double blind, multicentre comparison of hydrochlorothiazide, atenolol, nitrendipine, and enalapril in antihypertensive treatment: results of the HANE Study. BMJ. 1997;315154- 159
Link to Article
Stason  WBSchmid  CHNiedzwiecki  D  et al.  Safety of nifedipine in patients with hypertension: a meta-analysis. Hypertension. 1997;307- 14
Link to Article
Gong  LZhang  WZhu  Y  et al.  Shangai Trial of Nifedipine in the Elderly (STONE). J Hypertens. 1996;141237- 1245
Link to Article
Pogue  VAEllis  CMichel  JFrancis  CK New staging of the fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V) alters assessment of the severity and treatment of hypertension. Hypertension. 1996;28713- 718
Link to Article
Alderman  MHMadhavan  SCohen  H Antihypertensive drug therapy: the effect of JNC criteria on prescribing pattern and patient status through the first year. Am J Hypertens. 1996;9413- 418
Link to Article
Soumerai  SBMcLaughlin  TJAvorn  J Improving drug prescribing in primary care: a critical analysis of experimental literature. Milbank Q. 1989;67268- 317
Link to Article
Wilkes  MSDoblin  BHShapiro  MF Pharmaceutical advertisements in leading medical journals: experts' assessments. Ann Intern Med. 1992;116912- 919
Link to Article
West  ENewton  J Clinical guidelines: an ambitious national strategy [editorial]. BMJ. 1997;315324
Link to Article
Vogt  TMCurtis-Ireland  CCBlack  DCamel  GHughes  G Recruitment of elderly volunteers for a multicenter clinical trial: the SHEP pilot trial. Control Clin Trials. 1986;7118- 133
Link to Article
Sudilovsky  ACroog  SCrook  T  et al.  Differential effects of antihypertensive medications on cognitive functioning. Psychopharmacol Bull. 1989;25133- 138
Starr  JMWhalley  LJDeary  IJ The effects of antihypertensive treatment on cognitive function: results from the HOPE Study. J Am Geriatr Soc. 1996;44411- 415
Jensen  EDehlin  OHagberg  BSamuelsson  GSvensson  TLidfeldt  J Blood pressure in relation to medical, psychological and social variables in a population of 80-year-olds: survival during 6 years. J Intern Med. 1997;241205- 212
Link to Article
Heckbert  SRLongstreth  WTPsaty  BM  et al.  The association of antihypertensive agents with MRI white matter findings and with modified Mini–Mental State Examination in older adults. J Am Geriatr Soc. 1997;451423- 1433
Svetkey  LPGeorge  LKTyroler  HATimmons  PZBurchett  BMBlazer  DG Effects of gender and ethnic group on blood pressure control in the elderly. Am J Hypertens. 1996;9529- 535
Link to Article
Strulov  AEpstein  LHarth  ATamir  A Blood pressure and hypertension in an elderly population. Eur J Epidemiol. 1990;6160- 165
Link to Article
Psaty  BMLee  MSavage  PJRutan  GHGerman  PSLyles  MCardiovascular Health Study Collaborative Research Group, Assessing the use of medications in the elderly: methods and initial experience in the Cardiovascular Health Study. J Clin Epidemiol. 1992;45683- 692
Link to Article
Trenkwalder  PRuland  DStender  M  et al.  Prevalence, awareness, treatment and control of hypertension in a population over the age of 65 years: results from the Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY). J Hypertens. 1994;12709- 716
Link to Article
Staessen  JAFagard  RThijs  L  et al.  Subgroup and per-protocol analysis of the Randomization European Trial on Isolated Systolic Hypertension in the Elderly. Arch Intern Med. 1998;1581681- 1691
Link to Article
Bulpitt  CJFletcher  AEAmery  A  et al.  The Hypertension in the Very Elderly Trial (HYVET): rationale, methodology and comparison with previous trials. Drugs Aging. 1994;5171- 183
Link to Article
Hing  ESekscenski  EStrahan  G The National Nursing Home Survey, 1985: summary for the United States. Vital Health Stat 13. 1989;971- 249
Vaitkevicius  PVEsserwein  DMMaynard  AKO'Connor  FCFleg  JL Frequency and importance of postprandial blood pressure reduction in elderly nursing-home patients. Ann Intern Med. 1991;115865- 870
Link to Article
Mulrow  CDGerety  MBCornell  JELawrence  VAKanten  DN The relationship between disease and function and perceived health in very frail elderly. J Am Geriatr Soc. 1994;42374- 380
Williams  BBetley  C Inappropriate use of nonpsychotropic medications in nursing homes. J Am Geriatr Soc. 1995;43513- 519
Bild  DEFitzpatrick  AFried  LP  et al.  Age-related trends in cardiovascular morbidity and physical functioning in the elderly: the Cardiovascular Health Study. J Am Geriatr Soc. 1993;411047- 1056
Burt  VLCutler  JAHiggins  M  et al.  Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population: data from the Health Examination Surveys, 1960 to 1991. Hypertension. 1995;2660- 69
Link to Article
McGee  DCooper  RLiao  YDurazo-Arvizu  R Patterns of comorbidity and mortality risk in blacks and whites. Ann Epidemiol. 1996;6381- 385
Link to Article
Haan  MNWeldon  M The influence of diabetes, hypertension, and stroke on ethnic differences in physical and cognitive functioning in an ethnically diverse older population. Ann Epidemiol. 1996;6392- 398
Link to Article
Croft  JBGiles  WHPollard  RACasper  MLAnda  RFLivengood  JR National trends in the initial hospitalization for heart failure. J Am Geriatr Soc. 1997;45270- 275
Psaty  BMSavage  PJTell  GS  et al.  Temporal patterns of antihypertensive medication use among elderly patients: the Cardiovascular Health Study. JAMA. 1993;2701837- 1841
Link to Article

Figures

Place holder to copy figure label and caption

Percentages of patients with hypertension (HTN) treated with diuretics, β-blockers (BB), angiotensin-converting enzyme inhibitors (ACE-I), or calcium channel blockers (CCB), according to the absence or presence of concurrent cardiovascular comorbid conditions, such as coronary heart disease (CHD) and congestive heart failure (CHF).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Principal Characteristics of Hypertensive Patients*
Table Graphic Jump LocationTable 2. Principal Comorbid Clinical Conditions Among Hypertensive Patients*
Table Graphic Jump LocationTable 3. Overall Use of Antihypertensive Agents
Table Graphic Jump LocationTable 4. Factors Associated With Receiving at Least 1 Antihypertensive Agent*

References

Dannenberg  ALGarrison  RJKannel  WB Incidence of hypertension in the Framingham Study. Am J Public Health. 1988;78676- 679
Link to Article
Psaty  BMFurberg  CDKuller  LH  et al.  Isolated systolic hypertension and subclinical cardiovascular disease in the elderly: initial findings from the Cardiovascular Health Study. JAMA. 1992;2681287- 1291
Link to Article
National High Blood Pressure Education Program Working Group, National High Blood Pressure Education Program Working Group report on hypertension in the elderly. Hypertension. 1994;23275- 285
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Stamler  JStamler  RNeaton  J Blood pressure, systolic and diastolic, and cardiovascular risk: US population data. Arch Intern Med. 1993;153598- 615
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Glynn  RJField  TSRosner  BHebert  PRTaylor  JOHennekens  CH Evidence for a positive linear relation between blood pressure and mortality in elderly people. Lancet. 1995;345825- 829
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O'Donnell  CJRidker  PMGlynn  RJ  et al.  Hypertension and borderline isolated systolic hypertension increase risks of cardiovascular disease and mortality in male physicians. Circulation. 1997;951132- 1137
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Du  XCruickshank  KMcNamee  R  et al.  Case-control study of stroke and the quality of hypertension control in north west England. BMJ. 1997;314272- 276
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Psaty  BMSmith  NLSiscovick  DS  et al.  Health outcomes associated with antihypertensive therapies used as first-line agents: a systematic review and meta-analysis. JAMA. 1997;277739- 745
Link to Article
Gueyffier  FBoutitie  FBoissel  J-P  et al. (The INDANA Investigators), Effect of antihypertensive drug treatment on cardiovascular outcomes in women and men: a meta-analysis of individual patient data from randomized, controlled trials. Ann Intern Med. 1997;126761- 767
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Insua  JTSacks  HSLau  T-S  et al.  Drug treatment of hypertension in the elderly: a meta-analysis. Ann Intern Med. 1994;121355- 362
Link to Article
Mulrow  CDCornell  JAHerrera  CRKadri  AFarnett  LAguilar  C Hypertension in the elderly: implications and generalizability of randomized trials. JAMA. 1994;2721932- 1938
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Kostis  JBDavis  BRCutler  J  et al. SHEP Cooperative Research Group, Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA. 1997;278212- 216
Link to Article
Staessen  JAFagard  RThijs  L  et al.  Randomised, double blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet. 1997;350757- 764
Link to Article
Joint National Committee, The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1993;153154- 183
Link to Article
Joint National Committee, The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;1572400- 2448
Siegel  DLopez  J Trends in antihypertensive drug use in the United States: do the JNC V recommendations affect prescribing? JAMA. 1997;2781745- 1748
Link to Article
Manolio  TACutler  JAFurberg  CDPsaty  BMWhelton  PKApplegate  WB Trends in pharmacologic management of hypertension in the United States. Arch Intern Med. 1995;155829- 837
Link to Article
Monane  MGlynn  RJGurwitz  JHBohn  RLLevin  RAvorn  J Trends in medication choices for hypertension in the elderly: the decline of thiazides. Hypertension. 1995;251045- 1051
Link to Article
Glynn  RJBrock  DBHarris  T  et al.  Use of antihypertensive drugs and trends in blood pressure in the elderly. Arch Intern Med. 1995;1551855- 1860
Link to Article
Furberg  CDPsaty  BMMyers  JV Nifedipine: dose-related increase in mortality in patients with coronary disease. Circulation. 1995;921326- 1331[published correction appears in Circulation. 1996;93:1475-1476].
Link to Article
Psaty  BMHeckbert  SRKoepsell  TD  et al.  The risk of myocardial infarction associated with antihypertensive drug therapies. JAMA. 1995;274620- 625
Link to Article
Alderman  MHCohen  HRoqué  RMadhavan  S Effect of long-acting and short-acting calcium antagonists on cardiovascular outcomes in hypertensive patients. Lancet. 1997;349594- 598
Link to Article
Pahor  MGuralnik  JMCorti  MCFoley  JDCarbonin  PHavlik  RJ Long-term survival and use of antihypertensive medication in older persons. J Am Geriatr Soc. 1995;431191- 1197
Avorn  J Medication use and the elderly: current status and opportunities. Health Aff. Spring1995;276- 286
Gurwitz  JHCol  NFAvorn  J The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA. 1992;2681417- 1422
Link to Article
Elliott  WJ ALLHAT: the largest and most important clinical trial in hypertension ever done in the USA. Am J Hypertens. 1996;9409- 411
Link to Article
Fried  TRMor  V Frailty and hospitalization of long-term stay nursing home residents. J Am Geriatr Soc. 1997;45265- 269
Frohlich  ED Hypertension in the elderly: only the end of the beginning. Hypertension. 1994;23286- 287
Link to Article
Haydar  ZRRywick  TFleg  JL Isolated systolic hypertension in the nursing home. Nurs Home Med. 1997;541- 49
Morris  JNHawes  CFries  BE  et al.  Designing the national resident assessment instrument for nursing homes. Gerontologist. 1990;30293- 297
Link to Article
Bernabei  RGambassi  GMor  V The SAGE database: introducing functional outcomes in geriatric pharmaco-epidemiology. J Am Geriatr Soc. 1998;46251- 252
Bernabei  RGambassi  GLapane  K  et al.  Principal characteristics of the SAGE database: a new resource for research on outcomes in long-term care. J Gerontol. In press.
Gambassi  GLandi  FPeng  L  et al.  Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. Med Care. 1998;36167- 179
Link to Article
Not Available, Minimum Data Set Plus Training Manual.  Natick, Mass Eliot Press1991;
Hawes  CMorris  JNPhillips  CDMor  VFries  BENonemaker  S Reliability estimates for the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). Gerontologist. 1995;35172- 178
Link to Article
Morris  JNFries  BEMehr  DR  et al.  MDS Cognitive Performance Scale. J Gerontol. 1994;49M174- M182
Link to Article
Mor  VBranco  KFleishman  J  et al.  The structure of social engagement among nursing home residents. J Gerontol B Psychol Sci Soc Sci. 1995;50P1- P8
Link to Article
Mantel  N Chi-square tests with one degree of freedom: extension of the Mantel-Haenszel procedure. J Am Stat Assoc. 1963;58690- 700
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Amery  ABirkenhager  WBrixko  P  et al.  Efficay of antihypertensive drug treatment according to age, sex, blood pressure, and previous cardiovascular disease in patients over the age of 60. Lancet. 1986;2589- 592
Link to Article
Dahlof  BLindholm  LHHansson  LSchersten  BEkbom  TWester  P-O Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet. 1991;3381281- 1285
Link to Article
MRC Working Party, Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ. 1992;304405- 412
Link to Article
Monane  MBohn  RLGurwitz  JHGlynn  RJLevin  RAvorn  J The effects of initial drug choice and comorbidity on antihypertensive therapy compliance: results from a population-based study in the elderly. Am J Hypertens. 1997;10697- 704
Link to Article
Philipp  TAnlauf  MDistler  AHolzgreve  HMichaelis  JWellek  S Randomised, double blind, multicentre comparison of hydrochlorothiazide, atenolol, nitrendipine, and enalapril in antihypertensive treatment: results of the HANE Study. BMJ. 1997;315154- 159
Link to Article
Stason  WBSchmid  CHNiedzwiecki  D  et al.  Safety of nifedipine in patients with hypertension: a meta-analysis. Hypertension. 1997;307- 14
Link to Article
Gong  LZhang  WZhu  Y  et al.  Shangai Trial of Nifedipine in the Elderly (STONE). J Hypertens. 1996;141237- 1245
Link to Article
Pogue  VAEllis  CMichel  JFrancis  CK New staging of the fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V) alters assessment of the severity and treatment of hypertension. Hypertension. 1996;28713- 718
Link to Article
Alderman  MHMadhavan  SCohen  H Antihypertensive drug therapy: the effect of JNC criteria on prescribing pattern and patient status through the first year. Am J Hypertens. 1996;9413- 418
Link to Article
Soumerai  SBMcLaughlin  TJAvorn  J Improving drug prescribing in primary care: a critical analysis of experimental literature. Milbank Q. 1989;67268- 317
Link to Article
Wilkes  MSDoblin  BHShapiro  MF Pharmaceutical advertisements in leading medical journals: experts' assessments. Ann Intern Med. 1992;116912- 919
Link to Article
West  ENewton  J Clinical guidelines: an ambitious national strategy [editorial]. BMJ. 1997;315324
Link to Article
Vogt  TMCurtis-Ireland  CCBlack  DCamel  GHughes  G Recruitment of elderly volunteers for a multicenter clinical trial: the SHEP pilot trial. Control Clin Trials. 1986;7118- 133
Link to Article
Sudilovsky  ACroog  SCrook  T  et al.  Differential effects of antihypertensive medications on cognitive functioning. Psychopharmacol Bull. 1989;25133- 138
Starr  JMWhalley  LJDeary  IJ The effects of antihypertensive treatment on cognitive function: results from the HOPE Study. J Am Geriatr Soc. 1996;44411- 415
Jensen  EDehlin  OHagberg  BSamuelsson  GSvensson  TLidfeldt  J Blood pressure in relation to medical, psychological and social variables in a population of 80-year-olds: survival during 6 years. J Intern Med. 1997;241205- 212
Link to Article
Heckbert  SRLongstreth  WTPsaty  BM  et al.  The association of antihypertensive agents with MRI white matter findings and with modified Mini–Mental State Examination in older adults. J Am Geriatr Soc. 1997;451423- 1433
Svetkey  LPGeorge  LKTyroler  HATimmons  PZBurchett  BMBlazer  DG Effects of gender and ethnic group on blood pressure control in the elderly. Am J Hypertens. 1996;9529- 535
Link to Article
Strulov  AEpstein  LHarth  ATamir  A Blood pressure and hypertension in an elderly population. Eur J Epidemiol. 1990;6160- 165
Link to Article
Psaty  BMLee  MSavage  PJRutan  GHGerman  PSLyles  MCardiovascular Health Study Collaborative Research Group, Assessing the use of medications in the elderly: methods and initial experience in the Cardiovascular Health Study. J Clin Epidemiol. 1992;45683- 692
Link to Article
Trenkwalder  PRuland  DStender  M  et al.  Prevalence, awareness, treatment and control of hypertension in a population over the age of 65 years: results from the Starnberg Study on Epidemiology of Parkinsonism and Hypertension in the Elderly (STEPHY). J Hypertens. 1994;12709- 716
Link to Article
Staessen  JAFagard  RThijs  L  et al.  Subgroup and per-protocol analysis of the Randomization European Trial on Isolated Systolic Hypertension in the Elderly. Arch Intern Med. 1998;1581681- 1691
Link to Article
Bulpitt  CJFletcher  AEAmery  A  et al.  The Hypertension in the Very Elderly Trial (HYVET): rationale, methodology and comparison with previous trials. Drugs Aging. 1994;5171- 183
Link to Article
Hing  ESekscenski  EStrahan  G The National Nursing Home Survey, 1985: summary for the United States. Vital Health Stat 13. 1989;971- 249
Vaitkevicius  PVEsserwein  DMMaynard  AKO'Connor  FCFleg  JL Frequency and importance of postprandial blood pressure reduction in elderly nursing-home patients. Ann Intern Med. 1991;115865- 870
Link to Article
Mulrow  CDGerety  MBCornell  JELawrence  VAKanten  DN The relationship between disease and function and perceived health in very frail elderly. J Am Geriatr Soc. 1994;42374- 380
Williams  BBetley  C Inappropriate use of nonpsychotropic medications in nursing homes. J Am Geriatr Soc. 1995;43513- 519
Bild  DEFitzpatrick  AFried  LP  et al.  Age-related trends in cardiovascular morbidity and physical functioning in the elderly: the Cardiovascular Health Study. J Am Geriatr Soc. 1993;411047- 1056
Burt  VLCutler  JAHiggins  M  et al.  Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population: data from the Health Examination Surveys, 1960 to 1991. Hypertension. 1995;2660- 69
Link to Article
McGee  DCooper  RLiao  YDurazo-Arvizu  R Patterns of comorbidity and mortality risk in blacks and whites. Ann Epidemiol. 1996;6381- 385
Link to Article
Haan  MNWeldon  M The influence of diabetes, hypertension, and stroke on ethnic differences in physical and cognitive functioning in an ethnically diverse older population. Ann Epidemiol. 1996;6392- 398
Link to Article
Croft  JBGiles  WHPollard  RACasper  MLAnda  RFLivengood  JR National trends in the initial hospitalization for heart failure. J Am Geriatr Soc. 1997;45270- 275
Psaty  BMSavage  PJTell  GS  et al.  Temporal patterns of antihypertensive medication use among elderly patients: the Cardiovascular Health Study. JAMA. 1993;2701837- 1841
Link to Article

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