In This Issue of Archives of Internal Medicine FREE

The authors interviewed 84 seriously ill medical inpatients with poor prognoses about their satisfaction with care and their ratings of the quality of care they received using a recently developed and validated instrument called the Quality of End-of-Life Care and Satisfaction with Treatment scale. Patients gave physicians higher quality ratings than nurses (4.39 vs 4.24; P = .01). In ANOVA models, those with do-not-resuscitate orders and cared for by the house-staff service were the most likely to give physicians lower ratings of quality and satisfaction. Nurses were rated lower by patients who were depressed and by those cared for by the house-staff service. Although preliminary, these findings offer initial insight into experiences of hospitalized patients at the end of life.

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The authors examined the effect of antihypertensive s on incident cognitive impairment. Older adult African Americans (N = 1900) with preserved cognition at baseline were screened for dementia using the Community Screening Instrument for Dementia at 2 and 5 years. Within a year of screening, participants with a high likelihood of cognitive impairment had physical and neuropsychological examinations. Antihypertensives reduced the odds of incident cognitive impairment by 38% (OR, 0.62; 95% CI, 0.45-0.84). The authors conclude that use of antihypertensives is associated with preservation of cognitive function in older African Americans. Although the favorable effect of antihypertensives is likely moderated by blood pressure lowering, future studies are needed to confirm this.

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The recently published National Cholesterol Education Program (NCEP) III guidelines expands the number of US adults eligible for drug therapy to treat or prevent coronary heart disease from 13 million to 36 million. This is largely owing to an expansion of the definition of prior cardiovascular disease to include all occlusive events of the heart, brain, and peripheral arteries; the use of global risk assessment rather than just lipid parameters; and elevation of diabetes mellitus to a coronary heart disease risk equivalent. For patients with prior events as well as those with diabetes or a 10-year risk of 20% or greater, the low-density lipoprotein cholesterol (LDL-C) goal is less than 100 mg/dL (<2.59 mmol/L). For those without a prior event or diabetes and 10-year risk of 10% to 19%, the LDL-C goal is less than 130 mg/dL (<3.36 mmol/L), and for those with a 10-year risk less than 10%, the LDL-C goal is less than 160 mg/dL (<4.14 mmol/L). Drug therapy, primarily using statins, either alone or in combination, should be an adjunct, not alternative, to therapeutic lifestyle changes. The statin drugs decrease risk of myocardial infarction, stroke, cardiovascular death, and total mortality. Statins have the most conclusive body of evidence to support their use to favorably alter lipid levels, including their benefit-to-risk and benefit-to-cost ratios, so their increased use in accordance with the new NCEP III guidelines could avoid tens of thousands of premature deaths in the United States each year.

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After the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) Trial ended in February 1997, randomized patients were offered active study medication for a further period of observation. Throughout the follow-up period (median, 3.9 years), systolic/diastolic pressure was 7.0/3.2 mm Hg higher in 1417 control patients than in 1485 subjects randomized to active treatment. Compared with control, long-term antihypertensive therapy reduced the risk of dementia by 55% from 7.4 to 3.3 cases per 1000 patient-years (P<.001). Treatment of 1000 patients for 5 years can prevent 20 (95% confidence interval, 7-33) cases of dementia.