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Background: ambulatory blood pressure (ABPM) appears to be a more accurate predictor of cardiovascular outcome than blood pressure (BP) measured in the clinic setting in younger adults., Objectives: the purpose of this study was to determine if ABPM predicted total and cardiovascular mortality independently of clinic BP and other cardiovascular risk factors in those aged 65 years and over., Methods: one thousand one hundred and forty-four individuals aged 65 and over referred to a single BP clinic had 24-h ABP measurement and clinic measurement at baseline off treatment. There were 385 deaths (of which 246 were cardiovascular) during a mean follow-up period of 6.7 years., Results: with adjustment for gender, age, risk indices and also for clinic BP, a higher mean value of ABPM was an independent predictor of cardiovascular mortality. The relative hazard ratio for each 10-mmHg rise in systolic blood pressure (SBP) was 1.10 (1.06-1.18, P < 0.001) for daytime and 1.18 (1.11-1.25, P < 0.001) for night-time SBP. The hazard ratios for each 5-mmHg rise in diastolic blood pressure (DBP) were 1.05 (1.00-1.10, P = NS) for daytime and 1.09 (1.04-1.14, P < 0.001) for night-time diastolic pressure. The hazard ratios for night-time ABPM remained significant after adjustment for daytime ABPM., Conclusions: ambulatory measurement of BP is superior to clinic measurement in predicting cardiovascular mortality in elderly subjects. Night-time BP is the strongest predictor of outcome in this age group.

Background: Heart failure and stroke are major causes of morbidity and mortality in older people. Angiotensin converting enzyme inhibitors improve symptoms and survival in left ventricular systolic dysfunction. Anticoagulants are effective in stroke prevention in atrial fibrillation with aspirin being a less effective alternative., Objectives: To determine the prevalence of left ventricular systolic dysfunction, health services utilisation and prescribing of diuretics and angiotensin converting enzyme inhibitors in left ventricular systolic dysfunction, and the prevalence of atrial fibrillation and anti-platelet/thrombotic therapy in atrial fibrillation in older people in the community., Methods: 500 subjects were drawn by two-stage random sampling from 5,002 subjects aged 70 years and over living at home. Subjects were screened for atrial fibrillation and left ventricular systolic dysfunction using electrocardiography and echocardiography., Results: The population prevalence amongst older people of left ventricular systolic dysfunction was 9.8% and of atrial fibrillation 7.8%. More than two-thirds of those with left ventricular systolic dysfunction were not on angiotensin converting enzyme inhibitors. Of those in atrial fibrillation, 35% were taking aspirin, 24% were taking warfarin and 41% were on neither aspirin nor warfarin. Nearly 90% of older people in the community have had contact with their general practitioner over the past year, and over half of those with left ventricular systolic dysfunction have had contact with hospital-based services over the past 2 years., Conclusions: Left ventricular systolic dysfunction is under-treated in older people in the community. Despite the high level of contact with hospital and community-based services, the majority of those with systolic left ventricular dysfunction are not on angiotensin converting enzyme inhibitors and a significant proportion of those in atrial fibrillation are not on any treatment for stroke prevention.

Background: Good inhaler technique and medication concordance is important for symptom and disease control in chronic airways disease., Objectives: Establish the prevalence of inhaler use; the main inhaler devices used by older people at home; their ability to use the inhalers they have been prescribed; and the relationship between perceived ease of use and actual performance., Design: Cross-sectional population based study., Subjects: Subjects aged 70 years and over living at home., Methods: 500 subjects were randomly selected from 5002 subjects aged 70 years and over living at home. Inhalers used over the previous 24 hours were identified by a nurse on home visit. Those with cognitive impairment were excluded. Inhaler system was assessed and graded by a doctor as acceptable (perfect or minor errors) or unacceptable (major errors), using previously published criteria. Perceived ease of use of the device was rated as easy, moderate or difficult., Results: 423 subjects participated in the study. The population prevalence of inhaler use was 15.8% (12.0, 19.7). Of the 91 inhaler devices used, 39 (42.8%) were metered dose inhalers, 34 (37.4%) were metered dose inhalers with large volume spacers, and 18 (19.8%) were breath-actuated devices. Thirty-two subjects (82.1%) using metered dose inhalers had an acceptable technique compared with 33 (97.1%) of those using metered dose inhalers with large volume spacers and 13 (72.2%) of those using breath-actuated devices (P < 0.05). Up to three quarters of inhalers were considered easy to use but 12% of subjects who rated their inhaler device as being easy to use made major errors., Conclusion: Metered dose inhaler was the most frequently prescribed inhaler and was used correctly by most subjects especially in combination with large volume spacers. Major errors were more common with breath-actuated devices. Inhaler technique should be checked as patients' perception of their inhaler skills correlates poorly with actual performance.

Objectives: To determine the prevalence of dyspnoea in older people at home, measure its impact on function and quality of life, and identify associated cardio-respiratory diseases., Design: Cross-sectional population-based study., Methods: We sent a modified Medical Research Council (MRC) dyspnoea questionnaire to identify breathlessness in 1404 randomly selected subjects from general practitioner lists of 5002 subjects aged 70 years and over living at home. We visited a further random sample of 500 of these subjects at home and at a study centre., Setting: Community-based study in South Wales., Main Outcome Measures: Prevalence of dyspnoea (MRC grades 3-5) and its effect on psychological and functional status, and quality of life as measured by Hospital Anxiety and Depression, Nottingham Extended Activities of Daily Living and SF-36 questionnaires., Results: The prevalence of dyspnoea as defined was 32.3% (95% confidence intervals: 30.3, 34.3). Breathless subjects had poorer functional status than non-breathless subjects. They also had poorer physical and mental health and were more likely to be anxious and depressed. The prevalence of left ventricular systolic dysfunction, reversible airways disease and obesity were all higher in those with dyspnoea., Conclusions: Dyspnoea is common in older people. Given its profound adverse effect on people's lives, dyspnoea is an important public health issue.

The effects of discontinuing long-term diuretic therapy were investigated by means of a double-blind randomized controlled trial. A total of 141 elderly patients in the long-stay wards of six hospitals were found to be taking maintenance diuretics, and for 33 of these the drugs were judged to be mandatory. Of the remaining patients, 52 continued to receive diuretics while 54 were given matching placebo tablets. Eight in the latter group required diuretic therapy to be resumed during the following 12 weeks. The main change observed in patients who completed the trial was a slight increase of ankle oedema in the placebo group. Plasma potassium levels below 3.5 mEq/1 were found in some patients taking diuretics but not when the drugs had been withdrawn for 12 weeks. Blood pressure rose slightly in the placebo group and plasma urea rose slightly in the diuretic group. It was concluded that old people receiving long-term diuretic therapy without obvious current indication should have the drugs withdrawn under careful supervision so that those needing them could be identified.

Data are presented relating to the nutritional status of over 1500 elderly subjects seen in three community surveys. There was s decline in weight, arm circumference and skinfold thickness, and to a lesser extent in Quetelet's index (weight + height2), with advancing age. Haemoglobin levels declined with age in one area but not in the others, probably due to differences in nutritional state. Plasma protein and albumin concentrations showed no decline with age and were similar to values reported from younger subjects. Men who ate alone tended to have a poorer vitamin C and thiamine status than men whose meals were cooked or shared by another person, but no such difference was found among women; indeed, women eating alone had significantly higher leucocyte ascorbic acid levels.

A controlled cross-over trial of supplementary potassium was conducted in 46 elderly people whose dietary intake of potassium appeared to be no more than 45 mEq per day. Their grip strength and mental function were no better after two weeks' treatment with 48 mEq than when they received placebo tablets. It was concluded that the possible benefits of widespread potassium supplementation do not justify the risks which would be incurred.

Eight hundred and thirty elderly subjects who were seen in a nutritional survey were followed up after eight years. A marked decline of body weight with age, which had been evident in the original cross-sectional data, appeared to be due to a loss of weight in individuals rather than to any survival advantages of less obese persons. Indeed, over the age of 70 years the survivors tended to have been heavier when originally seen than those who died, suggesting that an above-average weight is a favourable prognostic factor in old age. There was a tendency for the women who died to have had lower ascorbic-acid levels than those who survived, but this was not obviously related to any one cause of death. Although it is possible that a poor vitamin C status increases mortality, the associations reported are probably due to the fact that elderly persons who are biologically younger than their contemporaries tend in consequence to be heavier and to have higher ascorbic acid levels and lower mortality rates than others of their chronological age.