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Background: Clinical inertia, provider failure to appropriately intensify treatment, is a major contributor to uncontrolled blood pressure (BP). Some clinical inertia may result from physician uncertainty over the patient's usual BP, adherence, or value of continuing efforts to control BP through lifestyle changes.Objective: To test the hypothesis that providing physicians with uncertainty reduction tools, including 24-h ambulatory BP monitoring, electronic bottle cap monitoring, and lifestyle assessment and counseling, will lead to improved BP control.Design: Cluster randomized trial with five intervention clinics (IC) and five usual care clinics (UCC).Setting: Six public and 4 private primary care clinics.Participants: A total of 665 patients (63 percent African American) with uncontrolled hypertension (BP ≥140 mmHg/90 mmHg or ≥130/80 mmHg if diabetic).Interventions: An order form for uncertainty reduction tools was placed in the IC participants' charts before each visit and results fed back to the provider.Outcome Measures: Percent with controlled BP at last visit. Secondary outcome was BP changes from baseline.Results: Median follow-up time was 24 months. IC physicians intensified treatment in 81% of IC patients compared to 67% in UCC (p < 0.001); 35.0% of IC patients and 31.9% of UCC patients achieved control at the last recorded visit (p > 0.05). Multi-level mixed effects longitudinal regression modeling of SBP and DBP indicated a significant, non-linear slope difference favoring IC (p (time × group interaction) = 0.048 for SBP and p = 0.001 for DBP). The model-predicted difference attributable to intervention was -2.8 mmHg for both SBP and DBP by month 24, and -6.5 mmHg for both SBP and DBP by month 36.Conclusions: The uncertainty reduction intervention did not achieve the pre-specified dichotomous outcome, but led to lower measured BP in IC patients. [ABSTRACT FROM AUTHOR]

Description of the key elements of elder neglect is critical to the development of a case definition. In this brief report, experienced protective service workers were surveyed to capture their field experiences with neglected elders. The workers cited environmental filth, poor personal hygiene and health related factors as the three most common observations. Workers also describe their definitions of the differences between self and caregiver neglect. [ABSTRACT FROM AUTHOR]

BACKGROUND: Mistreatment of adults, including abuse, neglect, and exploitation, affects more than 1.8 million older Americans. Presently, there is a lack of precise estimates of the magnitude of the problem and the variability in risk for different types of mistreatment depending on such factors as age and gender. OBJECTIVES: To describe the universe of case reports received during one year in a centralized computer database maintained by the Texas Department of Protective and Regulatory Services--Adult Protective Services Division (TDPRS-APS). DESIGN: Descriptive. SETTING: Texas. PARTICIPANTS: Mistreated or neglected older people. MEASUREMENTS: The distribution of abuse types reported and population prevalence estimates of each abuse type by age and sex. RESULTS: There were over 62,000 allegations of adult mistreatment and neglect filed in Texas in 1997. Neglect accounted for 80% of the allegations. The incidence of being reported to the TDPRS-APS increased sharply after age 65. The prevalence was 1,310 individuals/100,000 > or = 65 years of age for all abuse types. CONCLUSIONS: The TDPRS database is an excellent tool for characterizing and tracking cases of reported elder mistreatment. Achieving a clearer understanding of this ever-increasing public health problem can aid in the development of better interventions and prevention strategies. [ABSTRACT FROM AUTHOR]

Presently the available intervention in the state of Texas for abused or neglected elders is that delivered by the Texas Department of Protective and Regulatory Services. The Harris County Hospital District has a comprehensive Geriatric Program staffed by an interdisciplinary team. The purpose of this report is to describe the team's experience with nine neglected or abused elders who underwent interdisciplinary geriatric assessment and intervention with three and sixmonth follow-up. Two illustrative cases are described in detail. This series of nine patients who were neglected or abused illustrates the potential impact of a medical intervention program. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the response rates when random digit dialing was used as a substitute for geographic area sampling and household interviews to recruit 2100 African Americans for a blood pressure measurement and hypertension-related knowledge and attitudes survey. Methods. Random digit dialing was used to identify African American adults living in 12 low-income ZIP code areas of Houston, Texas. A brief survey of hypertension awareness and treatment was administered to all respondents. Those who self-identified as African American were invited to a community location for blood pressure measurement and an extended personal interview. An incentive of $10 was offered for the completed clinic visit. A substudy of nonrespondents was carried out to test the effectiveness of a $25 incentive in increasing the response rate. Data from the initial random telephone interview were used to identify differences between those who did and did not attend the measurement session. Results. Ninety-four percent of eligible persons contacted completed the telephone survey, and 65% agreed to visit a central community site for blood pressure measurement. In spite of the financial incentive and multiple attempts to reschedule missed appointments, only 26% of the 65% who agreed to attend completed the scheduled visit. In the substudy of the higher financial incentive, all of those who missed the original appointment agreed to another appointment, and 85% of this subgroup kept it. Not being employed full-time and a history of hypertension were consistently associated with agreement to be measured and keeping an appointment. In spite of the low response rate for scheduled appointments, differences-other than in employment status and a history of hypetension-between responders and nonresponders were small and consistent with what is usually observed in health surveys. Conclusions. The use of random digit dialing as a substitute for area sampling and household screening resulted in unacceptably low response rates in the study population and should not be undertaken without further research on ways to increase response rates. [ABSTRACT FROM AUTHOR]

The purpose of this study was to describe the health care access provided to a low-income urban population by a system of county run public clinics. We conducted a cross-sectional interview survey of a random sample of subjects applying for or renewing eligibility to use the public system. The setting was a public system consisting of inner-city community health centers and hospital-based clinics delivering primary care. We interviewed 547 adult nonpregnant subjects; mean age was 41 years; 55% were women, 54% were Hispanic and 28% were non-Hispanic Blacks; 78% had household income below $15,000 per year, and 75% had no health insurance. Access to health care was measured in three ways: physician contact during year prior to survey; and answers to two separate questions concerning delaying needed medical care because it cost too much, and delaying care because it would take too long to be seen. Although 80% of subjects had seen a physician at least once, 46% had stayed away sometime during the year due to financial reasons and 24% had stayed away because of waiting time. Surprisingly, 35% reported private sector use. These rates varied significantly with insurance status. Hispanics had significantly less access by all three measures, even after multivariable adjustment for potential confounders such as sex, age, chronic disease and insurance status. We conclude that this study demonstrates financial barriers to access, while showing substantial private sector contact, even by low-income subjects already using the public sector. [ABSTRACT FROM AUTHOR]

Objective: To evaluate an entertainment-based patient decision aid for prostate cancer screening among patients with low or high health literacy.Methods: Male primary care patients from two clinical sites, one characterized as serving patients with low health literacy (n=149) and the second as serving patients with high health literacy (n=301), were randomized to receive an entertainment-based decision aid for prostate cancer screening or an audiobooklet-control aid with the same learner content but without the entertainment features. Postintervention and 2-week follow-up assessments were conducted.Results: Patients at the low-literacy site were more engaged with the entertainment-based aid than patients at the high-literacy site. Overall, knowledge improved for all patients. Among patients at the low-literacy site, the entertainment-based aid was associated with lower decisional conflict and greater self-advocacy (i.e., mastering and obtaining information about screening) when compared to patients given the audiobooklet. No differences between the aids were observed for patients at the high-literacy site.Conclusion: Entertainment education may be an effective strategy for promoting informed decision making about prostate cancer screening among patients with lower health literacy.Practice Implications: As barriers to implementing computer-based patient decision support programs decrease, alternative models for delivering these programs should be explored. [ABSTRACT FROM AUTHOR]

The widespread treatment of hypertension and resultant improvement in blood pressure have been major contributors to the dramatic age-specific decline in heart disease and stroke. Despite this progress, a persistent gap remains between stated public health targets and achieved blood pressure control rates. Many factors may be important contributors to the gap between population hypertension control goals and currently observed control levels. Among them is the extent to which patients adhere to prescribed treatment. The goal of this scientific statement is to summarize the current state of knowledge of the contribution of medication nonadherence to the national prevalence of poor blood pressure control, methods for measuring medication adherence and their associated challenges, risk factors for antihypertensive medication nonadherence, and strategies for improving adherence to antihypertensive medications at both the individual and health system levels.

Competing Interests: The authors report no conflicts of interest.

Background: Many individuals with diabetes live in low- or middle-income settings. Glycemic control is challenging, particularly in resource-limited areas that face numerous healthcare barriers., Objective: To compare HbA1c outcomes for individuals randomized to TIME, a Telehealth-supported, Integrated care with CHWs (Community Health Workers), and MEdication-access program (intervention) versus usual care (wait-list control)., Design: Randomized clinical trial., Participants: Low-income Latino(a) adults with type 2 diabetes., Interventions: TIME consisted of (1) CHW-participant telehealth communication via mobile health (mHealth) for 12 months, (2) CHW-led monthly group visits for 6 months, and (3) weekly CHW-physician diabetes training and support via telehealth (video conferencing)., Main Measures: Investigators compared TIME versus control participant baseline to month 6 changes of HbA1c (primary outcome), blood pressure, body mass index (BMI), weight, and adherence to seven American Diabetes Association (ADA) standards of care. CHW assistance in identifying barriers to healthcare in the intervention group were measured at the end of mHealth communication (12 months)., Key Results: A total of 89 individuals participated. TIME individuals compared to control participants had significant HbA1c decreases (9.02 to 7.59% (- 1.43%) vs. 8.71 to 8.26% (- 0.45%), respectively, p = 0.002), blood pressure changes (systolic: - 6.89 mmHg vs. 0.03 mmHg, p = 0.023; diastolic: - 3.36 mmHg vs. 0.2 mmHg, respectively, p = 0.046), and ADA guideline adherence (p < 0.001) from baseline to month 6. At month 6, more TIME than control participants achieved > 0.50% HbA1c reductions (88.57% vs. 43.75%, p < 0.001). BMI and weight changes were not significant between groups. Many (54.6%) TIME participants experienced > 1 barrier to care, of whom 91.7% had medication issues. CHWs identified the majority (87.5%) of barriers., Conclusions: TIME participants resulted in improved outcomes including HbA1c. CHWs are uniquely positioned to identify barriers to care particularly related to medications that may have gone unrecognized otherwise. Larger trials are needed to determine the scalability and sustainability of the intervention., Clinical Trial: NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456.

Background: Community health workers (CHWs) are a well-established source to improve patient health care, yet their training and support remain suboptimal. This limits program expansion and potentially compromises patient safety. The objective of the study was to evaluate the feasibility and acceptability of weekly training and support by telemedicine (videoconferencing). Materials and Methods: CHWs (n = 6) who led diabetes group visits for low-income Latinos met weekly with a health care professional for training and support. Feasibility and acceptability outcome measures included telemedicine usability, knowledge of diabetes (baseline to 6 months), and program satisfaction. Results: Telemedicine training and support were found to be feasible and acceptable as measured by usability (Telehealth Usability Questionnaire: average 4.7/5.0, ±0.4), knowledge (Diabetes Knowledge Test: pretest 15.8 ± 1.3, posttest 21.8 ± 1.2, p < 0.001, respectively), and satisfaction (Texas Department of State Health Services survey: average 5.8/6.0, ±0.5). All CHWs preferred telemedicine to in-person training. Conclusions: Telemedicine is a feasible and acceptable modality to train and support CHWs.

Background: The vast majority of individuals diagnosed with diabetes are low/middle income and may have access to only three of the 11 oral hypoglycemic medications (OHMs) due to cost: metformin intermediate release (IR) or extended release (ER), sulfonylureas (glimepiride, glipizide, glyburide), and pioglitazone. Sulfonylureas and pioglitazone have had significant controversy related to potential adverse events, but it remains unclear whether these negative outcomes are class, drug, or dose-related., Objective: We conducted a narrative review of low-cost OHMs., Methods: We evaluated the maximum recommended (MAX) compared to the most effective (EFF) daily dose, time-to-peak change in HbA1c levels, and adverse events of low-cost oral hypoglycemic medications., Results: We found that the MAX was often greater than the EFF: metformin IR/ER (MAX: 2,550/2,000 mg, EFF: 1,500-2,000/1,500-2,000 mg), glipizide IR/ER (MAX: 40/20 mg, EFF: 20/5 mg), glyburide (MAX: 20 mg, EFF: 2.5-5.0 mg), pioglitazone (MAX: 45 mg, EFF: 45 mg). Time-to-peak change in HbA1c levels occurred at weeks 12-20 (sulfonylureas), 25-39 (metformin), and 25 (pioglitazone). Glimepiride was not associated with weight gain, hypoglycemia, or negative cardiovascular events relative to other sulfonylureas. Cardiovascular event rates did not increase with lower glyburide doses (p<0.05). Glimepiride and pioglitazone have been successfully used in renal impairment., Conclusion: Metformin, glimepiride, and pioglitazone are safe and efficacious OHMs. Prescribing at the EFF rather than the MAX may avoid negative dose-related outcomes. OHMs should be evaluated as individual drugs, not generalized as a class, due to different dosing and adverse-event profiles; Glimepiride is the preferred sulfonylurea since it is not associated with the adverse events as others in its class., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Prior studies have supported the efficacy of diabetes group visits. However, the benefit of diabetes group visits for low-income and underserved individuals is not clear. The purpose of this study was to conduct a narrative review in order to clarify the efficacy of diabetes group visits in low-income and underserved settings., Methods: The authors performed a narrative review, categorizing studies into nonrandomized and randomized., Results: A total of 14 studies were identified. Hemoglobin A1c was the most commonly measured outcome, which improved for the majority of group visit participants. Preventive care showed consistent improvement for intervention arms. There were several other study outcomes including metabolic (i.e., blood pressure), behavioral (i.e., exercise), functional (i.e., quality of life), and system-based (i.e., cost)., Conclusion: Diabetes group visits for low-income and underserved individuals resulted in superior preventive care but the impact on glycemic control remains unclear., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: There are variable recommendations regarding initiating monotherapy or dual therapy in patients with newly diagnosed type 2 diabetes (T2D). Clear initial strategies are of particular importance in underserved settings where access to care and financial burdens are significant barriers., Objectives: To provide descriptive data of metabolic outcomes to therapy regimens for low-income individuals with newly diagnosed T2D placed on oral hypoglycemic agents (OAs)., Methods: We conducted a retrospective chart review of low-income individuals with newly diagnosed T2D initiated on OAs. We provided descriptive data and then evaluated the effects of OA regimens (ie, mono-, dual-, transition [from mono to dual or vice versa] therapy) on hemoglobin A1c (A1c) (baseline to 12 months)., Results: A total of 309 patients were included in the study. At 12 months, the mean decrease in A1c for the entire sample was -2.36% (9.37% to 7.01%). Patients prescribed dual therapy had a greater change of A1c compared to those taking monotherapy with metformin (-1.11%, P < .01). Patients who transitioned therapies did not differ in change of A1c compared to monotherapy., Conclusion: Initiation of dual therapy was superior to metformin monotherapy or transitioning therapies and may be preferred for low-income individuals with newly diagnosed T2D.

Competing Interests: Conflicts of Interest/Disclosures: None for Drs. Ard, Arnett, Carter, Cooper, Cutler, Davis, Desvigne-Nickens, Diez Roux, Einhorn, Gavini, Go, Kimmel, Mensah, Miller, Mills, Ogedegbe, Rahman, Thomas, Tobin, Whelton, Wright, and Yoon. Dr. Appel has an institutional conflict of interest with Healthways, Inc. Dr. Cushman is an investigator for institutional grants from Eli Lilly and Boerhinger-Ingelheim, and has provided unpaid services for Takeda. Dr. Freedman and Wake Forest University Health Sciences have filed for a patent related to APOL1 genetic testing. Dr. Freedman receives grant support from Novartis Pharmaceuticals and is a consultant for Ionis Pharmaceuticals. Dr. Ferdinand is a consultant for Amgen, Sanofi, Eli Lilly, and Boehringer Ingleheim. Dr. Margolis served on an advisory board for Novartis Pharmaceuticals. Dr. Muntner receives research support from Amgen, Inc. Dr. Navar is an investigator for institutional grants from Sanofi and Regeneron pharmaceuticals. Dr. Taylor is on an advisory board for Amgen, Inc and for Alnylam Pharmaceuticals. The views expressed in this article do not necessarily represent the American Medical Association; National Institutes of Health; Centers for Disease Control and Prevention; or US Department of Health and Human Services.

Non-adherence has been a major concern in the treatment of hypertension and is particularly important in understanding and intervening in patients who appear to have resistant hypertension. Relatively few studies have examined the role of non-adherence in resistant hypertension. This review will address issues related to measurement of adherence, adherence interventions and rates of non-adherence in general hypertensive populations and in patients classified as having resistant hypertension.

Objectives: African-Americans (AAs) have a high prevalence of hypertension and their blood pressure (BP) control on treatment still lags behind other groups. In 2004, NHLBI funded five projects that aimed to evaluate clinically feasible interventions to effect changes in medical care delivery leading to an increased proportion of AA patients with controlled BP. Three of the groups performed a pooled analysis of trial results to determine: 1) the magnitude of the combined intervention effect; and 2) how the pooled results could inform the methodology for future health-system level BP interventions., Methods: Using a cluster randomized design, the trials enrolled AAs with uncontrolled hypertension to test interventions targeting a combination of patient and clinician behaviors. The 12-month Systolic BP (SBP) and Diastolic BP (DBP) effects of intervention or control cluster assignment were assessed using mixed effects longitudinal regression modeling., Results: 2,015 patients representing 352 clusters participated across the three trials. Pooled BP slopes followed a quadratic pattern, with an initial decline, followed by a rise toward baseline, and did not differ significantly between intervention and control clusters: SBP linear coefficient = -2.60±0.21 mmHg per month, p<0.001; quadratic coefficient = 0.167± 0.02 mmHg/month, p<0.001; group by time interaction group by time group x linear time coefficient=0.145 ± 0.293, p=0.622; group x quadratic time coefficient= -0.017 ± 0.026, p=0.525). RESULTS were similar for DBP. The individual sites did not have significant intervention effects when analyzed separately., Conclusion: Investigators planning behavioral trials to improve BP control in health systems serving AAs should plan for small effect sizes and employ a "run-in" period in which BP can be expected to improve in both experimental and control clusters.

Purpose: The goal of this study was to develop a technology-based strategy to identify patients with undiagnosed hypertension in 23 primary care practices and integrate this innovation into a continuous quality improvement initiative in a large, integrated health system., Methods: In phase 1, we reviewed electronic health records (EHRs) using algorithms designed to identify patients at risk for undiagnosed hypertension. We then invited each at-risk patient to complete an automated office blood pressure (AOBP) protocol. In phase 2, we instituted a quality improvement process that included regular physician feedback and office-based computer alerts to evaluate at-risk patients not screened in phase 1. Study patients were observed for 24 additional months to determine rates of diagnostic resolution., Results: Of the 1,432 patients targeted for inclusion in the study, 475 completed the AOBP protocol during the 6 months of phase 1. Of the 1,033 at-risk patients who remained active during phase 2, 740 (72%) were classified by the end of the follow-up period: 361 had hypertension diagnosed, 290 had either white-coat hypertension, prehypertension, or elevated blood pressure diagnosed, and 89 had normal blood pressure. By the end of the follow-up period, 293 patients (28%) had not been classified and remained at risk for undiagnosed hypertension., Conclusions: Our technology-based innovation identified a large number of patients at risk for undiagnosed hypertension and successfully classified the majority, including many with hypertension. This innovation has been implemented as an ongoing quality improvement initiative in our medical group and continues to improve the accuracy of diagnosis of hypertension among primary care patients., (© 2014 Annals of Family Medicine, Inc.)

Most studies on the prevalence and determinants of resistant hypertension (RH) do not account for white coat hypertension, medication non-adherence, or use of suboptimal treatment dosages. We studied the characteristics, drug combinations, and dosages of patients on at least three antihypertensives of different classes who had uncontrolled blood pressure on 24-hour ambulatory blood pressure monitoring and high medication adherence measured by electronic monitoring. The data were collected as part of the baseline measures of a hypertension control trial. Of 140 monitored primary care patients, all with uncontrolled office blood pressure, 69 (49%) were on at least three antihypertensives of different classes. Of these 69, 15 (22%) were controlled on ambulatory blood pressure monitoring, 20 (29%) were uncontrolled and non-adherent, leaving only 34 (49%) adherent to their medications and having uncontrolled ambulatory hypertension (uncontrolled RH). Thirty-one (91%) of the 34 uncontrolled RH patients were prescribed a diuretic, of which 24 were on hydrochlorothiazide 25 mg. Less than half of the patients on angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, or calcium channel blocker were prescribed maximal doses of these agents. Half of the RH can be attributed to white coat effect and poor medication adherence, and all of the remaining patients were on apparently suboptimal drug combinations and/or dosages. Primary care physicians need to be educated regarding the optimal treatment of RH., (Copyright © 2013 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.)

Behavioral risk factors are among the preventable causes of health disparities, yet long-term change remains elusive. Many interventions are designed to increase self-efficacy, but little is known about the effect on long-term behavior change in older, low-income African Americans, especially when facing more problematic barriers. A cohort of 185 low-income African-Americans with hypertension reported barriers they encountered while undergoing a multiple behavior change trial from 2002 to 2006. The purpose of the present study was to explore the relationships between self-efficacy, barriers, and multiple behavior change over time. Higher self-efficacy seemed to be partially helpful for smoking reduction and increasing physical activity, but not for following a low-sodium diet. Addiction was indirectly associated with less reduction in smoking through lower self-efficacy. Otherwise, different barriers were associated with behavior change than were associated with self-efficacy: being "too busy" directly interfered with physical activity and "traditions" with low-sodium diet; however, they were neither the most frequently reported barriers, nor associated with lower self-efficacy. This suggests that an emphasis on self-efficacy alone may be insufficient for overcoming the most salient barriers encountered by older African Americans. Additionally, the most common perceived barriers may not necessarily be relevant to long-term behavioral outcomes.

Nonadherence to medications is an important cause of poor blood pressure control. Long-acting antihypertensive agents could theoretically be beneficial in partially adherent patients, who are commonly seen in contemporary practice. Little has been reported about the duration of drug holidays (DHs) in treated hypertensives outside of generally compliant patients in phase 4 clinical trials. The authors described patterns of nonadherence to single and multiple antihypertensives in a random sample of 120 primary care patients with uncontrolled hypertension. Adherence to up to 3 antihypertensives was measured by electronic monitoring. Frequencies of single-day omissions and DHs of 2 consecutive days (DH2), 3 days (DH3), or ≥4 days (DH≥4) for each drug were calculated. Overall, 89 (74%) of patients had at least a 1-day omission. A single day omission was found in 61.4% of the patients taking 1 drug, followed by DH≥4 (28.1%), DH2 (26.3%), and DH3 (8.8%). In patients using multiple drugs, single-day omissions were also most common, followed by DH≥4, DH2, and DH3. Omissions of ≤3 days comprise on average 74% of all omissions. Although encouraging full adherence remains important, it may be prudent to prescribe long-acting antihypertensive agents, which can compensate for the majority of dose omissions., (© 2012 Wiley Periodicals, Inc.)

Background: Most studies on patient-related predictors of adherence used self-reported measures or pharmacy databases to measure adherence. We identified predictors of antihypertensive medication adherence measured by Medication Event Monitoring System (MEMS), the gold standard for adherence assessment, in uncontrolled, predominantly African-American (AA) hypertensives from large urban public and private primary care clinics., Methods: As part of the baseline data collection of a cluster-randomized trial for hypertension control, we measured adherence in a random sample of 124 participants using MEMS caps. We also included the data of 52 patients in intervention clinics who subsequently completed MEMS monitoring on referral from their provider. Participants were classified as adherent if they took ≥ 80% of all prescribed doses. Multivariate logistic regression was used to predict adherence., Results: Of 176 patients monitored, 61 (34.6%) took <80% of prescribed doses. AA ethnicity (odds ratio (OR) AA vs. Hispanic = 0.36; 95% confidence interval (CI) 0.15-0.86), female sex (OR = 0.38; 95% CI 0.15-0.91), and public clinics as source of care (OR public clinics vs. private clinics = 0.45; 95% CI 0.20-0.97) were independently associated with lower adherence. Higher adherence was seen in patients monitored by clinician order in the intervention clinics (OR intervention sample vs. random baseline sample = 2.15; 95% CI 0.96-4.81) and diabetic patients (OR = 2.05; 95% CI 1.01-4.15). All analyses were adjusted for education, employment status, and other potentially confounding factors., Conclusions: AA ethnicity, female gender and attending a publicly funded primary care clinic were associated with lower adherence. Whether targeting these groups for special interventions would improve overall adherence needs further study.

Warfarin is widely used as an oral anticoagulant for the prevention and long-term treatment of venous thromboembolism and for the prevention of thromboembolic complications associated with atrial fibrillation, heart valve replacement and myocardial infarction. Warfarin exerts its anticoagulation effect by inhibiting the enzymes responsible for the cyclic interconversion of vitamin K in the liver. Vitamin K serves as a cofactor required for the carboxylation of the vitamin K-dependent coagulation proteins. By inhibiting the supply of vitamin K in the production of these proteins, warfarin indirectly slows their rate of synthesis. The authors describe a 46-year-old patient readily anticoagulated for a deep venous thrombosis who then required large doses of warfarin after initiation of total parenteral nutrition, which included lipid preparation that contained vitamin K, in addition to vitamin K required for the daily parenteral nutrition. The effect of total parenteral nutrition with vitamin K on anticoagulation is discussed.

Hypertension (especially systolic hypertension) is very common in older persons. Systolic hypertension occurs because large conduit arteries become stiffer with age. Strong evidence from randomized trials suggests that treating systolic blood pressures initially higher than 160 mm Hg is extremely beneficial, and a recent trial extended this conclusion to healthy persons over 80 years of age. However, the only trial that has directly tested the use of more aggressive treatment goals (< 140 mm Hg) in the elderly did not show benefit in those older than 75. Risks of overtreating hypertension for the elderly include falls and orthostatic hypotension, and the most compromised older persons may be the most likely to experience adverse effects. Our current state of knowledge requires clinical judgment that balances the immediacy of adverse effects versus the potential but unproven benefits of treatment in deciding whether to treat the elderly more aggressively than the goals used in randomized trials.

Hypertension affects nearly one third of the US population overall, and the prevalence rises sharply with age. In spite of public educational campaigns and professional education programs to encourage blood pressure measurement and control of both systolic and diastolic control to <140/90 mm Hg (or 130/80 mm Hg if diabetic), 43% of treated hypertensives do not achieve the recommended Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure target. Among blacks, 48% are uncontrolled on treatment. The majority of persons classified as poorly controlled hypertensives have mild systolic blood pressure elevation (in the range of 140 to 160 mm Hg). We hypothesized that physician uncertainty regarding the patient's usual blood pressure, as well as uncertainty regarding the extent of medication nonadherence, represent an important barrier to further reductions in the proportion of uncontrolled hypertensives in the United States. Using cluster randomization, 10 primary care clinics (6 from a public health care system and 4 from a private clinic system) were randomized to either the uncertainty reduction intervention condition or to usual care. An average of 68 patients per clinic were recruited to serve as units of observation. Physicians in the 5 intervention clinics were provided with a specially designed study form that included a graph of recent blood pressure measurements in their study patients, a check box to indicate their assessment of the adequacy of the patient's blood pressure control, and a menu of services they could order to aid in patient management. These menu options included 24-hour ambulatory blood pressure monitoring; electronic bottle cap assessment of medication adherence, followed by medication adherence counseling in patients found to be nonadherent; and lifestyle assessment and counseling followed by 24-hour ambulatory blood pressure monitoring. Physicians in the 5 usual practice clinics did not have access to these services but were informed of which patients had been enrolled in the study. Substudies carried out to further characterize the study population and interpret intervention results included ambulatory blood pressure monitoring and electronic bottle cap monitoring in a random subsample of patients at baseline, and audio recording of patient-physician encounters after intervention implementation. The primary study end point was defined as the proportion of patients with controlled blood pressure (<140/90 mm Hg or <130/80 mm Hg if diabetic). Secondary end points include actual measured clinic systolic and diastolic blood pressure, patient physician communication patterns, physician prescribing patient self-reported lifestyle and medication adherence, physician knowledge, attitude and beliefs regarding the utility of intervention tools to achieve blood pressure control, and the cost-effectiveness of the intervention. Six-hundred eighty patients have been randomized, and 675 remain in active follow-up after 1.5 years. Patient closeout will be complete in March 2009. Analyses of the baseline data are in progress. Office-based blood pressure measurement error and bias, as well as physician and patient beliefs about the need for treatment intensification, may be important factors that limit further progress in blood pressure control. This trial will provide data on the extent to which available technologies not widely used in primary care will change physician prescribing behavior and patient adherence to prescribed treatment.

Background: Many patients in primary care settings present with multiple behavioral risk factors for cardiovascular disease. Research has provided little information on the most effective ways to approach multiple behavior change counseling in clinical settings., Methods: We implemented a randomized trial in a publicly funded primary care setting to test whether a sequential presentation of stage of change-based counseling to stop smoking, reduce dietary sodium level to less than 100 mEq/L per day, and increase physical activity by at least 10,000 pedometer steps per week would be more effective than simultaneous counseling. African Americans with hypertension, aged 45 to 64 years, initially nonadherent to the 3 behavioral goals, were randomized to the following conditions: (1) 1 in-clinic counseling session on all 3 behaviors every 6 months, supplemented by motivational interviewing by telephone for 18 months; (2) a similar protocol that addressed a new behavior every 6 months; or (3) 1-time referral to existing group classes ("usual care"). The primary end point was the proportion in each arm that met at least 2 behavioral criteria after 18 months., Results: A total of 289 individuals (67.3% female) were randomized, and 230 (79.6%) completed the study. At 18 months, only 6.5% in the simultaneous arm, 5.2% in the sequential arm, and 6.5% in the usual-care arm met the primary end point. However, results for single behavioral goals consistently favored the simultaneous group. At 6 months, 29.6% in the simultaneous, 16.5% in the sequential, and 13.4% in the usual-care arms had reached the urine sodium goal (P = .01). At 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usual-care arms were urine cotinine negative (P = .08)., Conclusions: Long-term multiple behavior change is difficult in primary care. This study provides strong evidence that addressing multiple behaviors sequentially is not superior to, and may be inferior to, a simultaneous approach.

In the Third National Health and Nutrition Examination Survey (NHANES III), three measures of cognitive function [Simple Reaction Time Test (SRTT), Symbol Digit Substitution Test (SDST), and Serial Digit Learning Test (SDLT)] were administered to a half-sample of 3,385 adult men and nonpregnant women 30-59 years of age with no history of stroke. We used multiple linear regression analysis to determine whether there was an independent association between performance on each cognitive function measure and defined hypertension (HTN) alone, type 2 diabetes mellitus (DM) alone, and coexistent HTN and DM after adjustment for demographic and socioeconomic variables and selected health behaviors. After adjustment for the sociodemographic variables, the combination of HTN + DM, but not HTN alone or DM alone, was significantly associated with worse performance on the SRTT (p = 0.031) and the SDST (p = 0.011). A similar pattern was observed for SDLT performance, but the relationship did not reach statistical significance (p = 0.101). We conclude that HTN in combination with DM is associated with detectable cognitive decrements in persons under age 60.

Description of the key elements of elder neglect is critical to the development of a case definition. In this brief report, experienced protective service workers were surveyed to capture their field experiences with neglected elders. The workers cited environmental filth, poor personal hygiene and health related factors as the three most common observations. Workers also describe their definitions of the differences between self and caregiver neglect.

Background: Hispanics have a high prevalence of cardiovascular risk factors, most notably type 2 diabetes. However, in a large public hospital in Houston, Texas, Hispanic patients referred for cardiac stress testing were significantly more likely to have normal test results than were Whites or non-Hispanic Blacks. We undertook an exploratory study to determine if nervios, a culturally based syndrome that shares similarities with both panic disorder and anginal symptoms, is sufficiently prevalent among Hispanics referred for cardiac testing to be considered as a possible explanation for the high probability of a normal test result., Methods: Hispanic patients were recruited consecutively when they presented for a cardiac stress test. A bilingual interviewer administered a brief medical history, the Rose Angina Questionnaire (RAQ), a questionnaire to assess a history of nervios and associated symptoms, and the PRIME-MD, a validated brief questionnaire to diagnose DSM-IV defined affective disorders., Results: The average age of the 114 participants (38 men and 76 women) was 57 years, and the average educational attainment was 7 years. Overall, 50% of participants reported a history of chronic nervios, and 14% reported an acute subtype known as ataque de nervios. Only 2% of patients had DSM-IV defined panic disorder, and 59% of patients had a positive RAQ score (ie, Rose questionnaire angina). The acute subtype, ataque de nervios, but not chronic nervios, was related to an increased probability of having Rose questionnaire angina (P=.006). Adjusted for covariates, a positive history of chronic nervios, but not Rose questionnaire angina, was significantly associated with a normal cardiac test result (OR=2.97, P=.04)., Conclusion: Nervios is common among Hispanics with symptoms of cardiac disease. Additional research is needed to understand how nervios symptoms differ from chest pain in Hispanics and the role of nervios in referral for cardiac workup by primary care providers and emergency room personnel.

Background: Internal medicine residency programs have increased the time devoted to ambulatory medicine and the range of nonmedical areas in which expertise is expected. Whether existing teaching locations can provide residents with appropriate training in educationally targeted specialty (ETS) conditions (otolaryngology, urology, dermatology, ophthalmology, and orthopedics), is unknown., Methods: An urgent care center (UCC) was developed at a teaching hospital to provide residents with additional experience in ambulatory medicine. To assess the frequency and nature of conditions seen by residents, 500 charts in the UCC, 500 charts in the resident continuity clinic (RCC), and 500 charts in the emergency room (ER) were selected at random and reviewed during a 2-month study period. Complaints were classified into three categories: general medicine, ETS conditions, and miscellaneous (upper respiratory infection, gynecology, and psychiatry)., Results: Four hundred seventy-six (95.2%) patients in the UCC and 491 (98.2%) patients in the ER had acute problems as compared with 236 (47.2%) patients in the RCC (P < 0.001). The number of ETS conditions was 302 (UCC), 104 (RCC), and 89 (ER; P < 0.001). The number in each category was otolaryngology, 88 (UCC), 17 (RCC), 19 (ER); urology, 43 (UCC), 10 (RCC), 14 (ER); dermatology, 41 (UCC), 11 (RCC), 11 (ER); ophthalmology, 25 (UCC), 7 (RCC), 10 (ER); and orthopedics, 105 (UCC), 59 (RCC), 35 (ER)., Conclusion: Patients with ETS conditions were seen more often by residents in the UCC than in the other locations. In our institution, a UCC provides a useful opportunity for the clinical and didactic education of internal medicine residents in areas of acute care that were underrepresented in other rotations. New educational programs may be needed to ensure the education of residents in ambulatory medicine.

Purpose of Review: We will summarize the latest available data on hypertension control levels in different populations throughout the world, and review the factors that appear to contribute to the widespread lack of blood pressure control in identified hypertensive patients., Recent Findings: Population surveys throughout the world indicate that the proportion of hypertensive patients with blood pressure controlled to below 140/90 mmHg ranges from 5% in Taiwan to 25% in the United States. Studies in the US have shown that the majority of hypertensive patients classified as uncontrolled have diastolic pressure below 90 mmHg with mild systolic elevation in the 140-160 mmHg range, and that these blood pressure levels rarely elicit a treatment intensification action by the physician. The results of the Antihypertensive and Lipid Lowering to Prevent Heart Attack Trial indicate that it is feasible to maintain average blood pressures on treatment to levels well below 140/90 mmHg in elderly hypertensive patients in primary care settings. Although the literature on automated blood pressure measurement and comparisons between office blood pressure and home blood pressure continues to grow, there has been little attention paid to practicing physicians' attitudes and beliefs about different blood pressure measurement methods, or to the feasibility of standardizing blood pressure measurement in typical practice settings., Summary: The experience in the US indicates that widely publicized treatment guidelines recommending blood pressure control targets and choice of first-line agents may have little influence on practicing physicians, even when based on solid evidence from clinical trials. Controversies in the literature regarding treatment targets, appropriate drug choices, and blood pressure monitoring methods are likely to delay improvements in overall population control.

Hypertension is the most widely treated cardiovascular risk factor, and there is clear evidence of the efficacy of treating systolic and diastolic blood pressure with existing antihypertensive agents in reducing stroke and cardiac disease. However, only about 25% of the US population has blood pressure controlled to at least 140 mm Hg systolic and 90 mm Hg diastolic. Hypertension control is a complex function of patient and physician behavior. Although poor hypertension control has historically been attributed to lack of health insurance or low utilization of available services, recently published analyses of national survey data and local physician and community samples suggest that physicians have a permissive attitude toward isolated mild systolic blood pressure elevations in the range of 140 to 160 mm Hg. The great majority of participants in health surveys report seeing a physician at least two times per year, and several investigators have documented that physicians are unlikely to increase treatment intensity for systolic elevations alone. Physician inaction toward elevated systolic blood pressure may be due to a reluctance to prescribe multiple drugs and/or lack of belief in the benefits of aggressive treatment to lower systolic blood pressure below 140 mm Hg.

An independent, inverse association between cognitive function and all-cause mortality has been reported in elderly cohorts. The purpose of this study was to determine whether the same association exists in middle-aged persons. The Atherosclerosis Risk in Communities Study is a cohort study initiated in 1987 to investigate the development of atherosclerosis in middle-aged persons. Three cognitive function measures were included in the second cohort examination conducted from 1990 to 1992 when the participants were aged 48-67 years: the Delayed Word Recall Test (DWRT), the Digit Symbol Substitution Test (DSST) (a subtest from the Wechsler Adult Intelligence Scale-Revised), and the Word Fluency Test from the Multilingual Aphasia Examination. Cox proportional hazards modeling was used to determine whether all-cause mortality ascertained through 1997 was associated with each measure after adjustment for sociodemographic, biologic, psychologic, and behavioral risk factors. Without adjustment, there was a significantly lower mortality hazard associated with higher scores on all three measures. After covariate adjustment, the hazard ratios for the DWRT and the DSST remained significant (hazard ratio1-point DWRT score increment = 0.90, 95% confidence interval: 0.84, 0.97; hazard ratio 7-point DSST score increment = 0.86, 95% confidence interval: 0.80, 0.93). Cognitive function measured in middle age appears to have prognostic importance for life expectancy similar to that reported in elderly adults.

Physician behavior--not patient noncompliance--is the major cause of poor hypertension control in the United States, many studies show. Hypertension control is unlikely to improve unless physicians become more aggressive in treating mildly elevated systolic blood pressure.

The G-protein beta3 subunit 825 TT genotype has been associated with obesity and hypertension. We examined the interaction between the G-protein TT genotype, physical activity and body mass index (BMI) in a cross-sectional study of African immigrants and African Americans. The genotype frequencies were 6.3% CC, 37.7% CT, and 56% TT. After adjusting for potential confounders, BMI was found to be significantly higher in the sedentary than in the physically active participants (p=0.045). There was no statistically significant effect for genotype (p=0.215) or the interaction between genotype and the level of physical activity (p=0.219). However, the individuals with the CC or CT genotype who were physically active had substantially lower BMIs (M+/-SE) (i.e., 25.74+/-2.02) than any of the other groups: sedentary CC + CT (30.58+/-1.03), sedentary TT (30.65+/-1.00) or active TT (29.43+/-1.65). Because of the low statistical power of this study, further research is needed to confirm these findings and to explore potential gene-environment/lifestyle interactions.

Background: Up to 2 million elderly persons are abused or neglected in the United States each year. Although elderly patients see their physicians an average of five times per year, physicians make only a small percentage of reports to Adult Protective Services (APS) agencies. The purpose of this study was to learn how practicing geriatricians define, diagnose, and address abuse and neglect to provide some guidance to the busy general internist regarding this complex issue., Methods: Ten local geriatricians were interviewed with a standardized set of open-ended questions. A team analyzed the verbatim transcriptions using both quantitative and qualitative methods., Results: The average number of cases diagnosed per year was 8.7 (range, 2-20). The geriatricians were fairly consistent in their definitions of elder abuse and neglect and how they diagnosed it through the history and physical exam. The most common findings in the history were rapport between the patient and caregiver, medical noncompliance, activities of daily living and instrumental activities of daily living assessments, and loss of social activities. The most common findings on the physical exam were bruising/trauma, general appearance/hygiene, malnutrition, and dehydration., Conclusions: The geriatricians emphasized keeping the diagnosis of abuse and neglect in mind for every patient. A variety of interventions were employed by physicians and ranged from automatically calling APS on each case to addressing cases through work with an interdisciplinary geriatrics team.

Dental diseases are widespread and are often underrecognized and treated. Caries and periodontal disease are common dental conditions that cause the majority of tooth loss. Although these conditions are preventable, many persons do not receive regular dental care and have acute problems when seen by their physician. Dental diseases frequently affect patients with multiple systemic disorders, including autoimmune disorders, diabetes, and human immunodeficiency virus (HIV) infection. The presence of dental disease may trigger inflammatory responses and have systemic consequences. Since dental disease affects almost all individuals, physicians should be able to recognize common conditions such as caries, periodontal disease, pulpitis, and dental abscess. In addition to initiating treatment and appropriate dental referrals, physicians should be familiar with the management of antibiotics and medications in the perioperative period. Another important role for physicians is to help reduce the societal and economic impact of these diseases through patient education and prevention.

The complexity of factors influencing the development of hypertension (HTN) in African Americans has given rise to theories suggesting that genetic changes occurred due to selection pressures/genetic bottleneck effects (ie, constriction of existing genetic variability) over the course of the slave trade. Ninety-nine US-born and 86 African-born health professionals were compared in a cross-sectional survey examining genetic and psychosocial predictors of HTN. We examined the distributions of three genetic loci (G-protein, AGT-235, and ACE I/D) that have been associated with increased HTN risk. There were no significant differences between US-born African Americans and African-born immigrants in the studied genetic loci or biological variables (eg, plasma renin and angiotensin converting enzyme activity), except that the AGT-235 homozygous T genotype was somewhat more frequent among African-born participants than US-born African Americans. Only age, body mass index, and birthplace consistently demonstrated associations with HTN status. Thus, there was no evidence of a genetic bottleneck in the loci studied, ie, that US-born African Americans have different genotype distributions that increase their risk for HTN. In fact, some of the genotypic distributions evidenced lower frequencies of HTN-related alleles among US-born African Americans, providing evidence of European admixture. The consistent finding that birthplace (ie, US vs Africa) was associated with HTN, even though it was not always significant, suggests potential and unmeasured cultural, lifestyle, and environmental differences between African immigrants and US-born African Americans that are protective against HTN.

OBJECTIVES: To describe the systolic and diastolic blood pressure criteria used by community physicians to: 1) establish a diagnosis of hypertension; and 2) increase dosage or change drug therapy in treated hypertensives. METHODS: A multiethnic population sample of adults at or above 40 years old was surveyed, by random digit phone dialing in a major metropolitan area, regarding blood pressure measurement and hypertension awareness and treatment status. Respondents with and without known hypertension were asked to: 1) identify their health care providers; and 2) agree to sign and return a release form allowing the investigators to obtain copies of their medical records. Medical records received were abstracted in a standardized format. RESULTS: Medical records were obtained for 169 patients who collectively had 940 visits with 175 different providers during a consecutive 2-year period. Overall, 25% of these patients had 24-month average blood pressures of at or above 140/90 mm Hg without a diagnosis of hypertension being recorded by a physician. Over two-thirds of the undiagnosed had systolic blood pressure of 140-159 mm Hg, with diastolic pressure of less than 90 mm Hg. In persons on antihypertensive drugs (n equals 81), the average blood pressure was 147/86 mm Hg, and only 24% met the Joint National Committee-VI blood pressure goal of less than 140/90 mm Hg. A visit-level analysis indicated that when diastolic blood pressure was greater than 90 mm Hg, physicians intensified drug therapy 24% of the time, but intensification actions occurred in only 4% of visits when systolic pressure was less than 140 mm Hg and diastolic pressure was less than 90 mm Hg. Kaplan-Meier survival curves and multiple logistic regression modeling demonstrated that almost no action would be taken for persistently elevated systolic blood pressure over 20 consecutive visits. CONCLUSIONS: Community physicians do not give equal weight to systolic blood pressure of greater than 140 mm Hg as to diastolic pressure of greater than 90 mm Hg in diagnosing hypertension and intensifying treatment. This is a major determinant of the current level of unawareness of hypertension and uncontrolled, known hypertension found in national surveys. (c)2000 by Le Jacq Communications, Inc.

Both genetic and environmental factors have been hypothesized to explain the higher prevalence of hypertension in US African Americans compared to populations still residing in western Africa. Studies of first-generation immigrants can help to identify risk factors for increased chronic disease expression in the developed world. Since we could identify no prior studies of hypertension in African immigrants to the United States, we conducted a cross-sectional survey of African-born and US-born African-American health professionals to compare the two groups for the prevalence of hypertension (blood pressure > or = 140/90 mm Hg or use of antihypertensive medication) and risk factors for hypertension (body mass index, lifestyle factors, and psychosocial variables hypothesized to relate to hypertension). Subjects were registered pharmacists and nurses recruited by mail. For the 182 individuals who completed study measurements (95 US-born and 87 African-born), the unadjusted odds ratio for hypertension associated with birthplace was 2.16 (95% CI = 1.12, 3.98). After adjustment for body mass index and age, the OR for birthplace was 1.92 (95% CI = 0.92, 4.00). No lifestyle or psychosocial variables were associated with hypertension prevalence. We conclude that there is a lower prevalence of hypertension in first-generation African immigrants that cannot be readily explained by the environmental effects measured in this study. Larger scale studies with African immigrants could advance understanding of the causes of the increased hypertension prevalence in US-born African Americans.

Lack of a nocturnal decline in blood pressure (BP) has been associated with more severe end organ damage in hypertensives, and blacks appear less likely than whites to have a > 10% drop in nighttime BP ("dipping"). Little information is available about the relationship between treatment regimens, ethnic group classification, and dipping in treated hypertensive patient populations. We obtained 24-h ambulatory BP readings in 438 adult white (n = 103), black (n = 200) and Hispanic (n = 135) treated hypertensives. Tycos monitors were connected in patients' homes before their usual morning medication dose time. Research assistants administered a quality-of-life questionnaire, recorded patients' drug regimen, and observed the patients take their morning dose. Monitors were programmed to record BP every 30 min. Dippers were defined as persons who had a drop of > or = 10% decline in average daytime (08:00 to 22:00) compared to nighttime (00:00 to 04:00) BP. Logistic regression modeling was used to assess the relationship between demographic and treatment variables and probability of dipping. Twenty-four-hour average BP was similar in all three ethnic groups. However, the absence of a systolic dip was significantly more common in black and Hispanic men than in white men (OR black v white = 11.54, 95% CI = 3.92 to 34.01; OR Hispanic v white = 7.32, 95% CI = 2.47 to 21.68). There were no ethnic group differences in probability of systolic dipping among women. Absence of a diastolic dip was approximately twice as common in blacks and Hispanics than in whites, with no marked gender-by-ethnic-group interaction in the magnitude of the association. Of the 10 most commonly prescribed antihypertensives, no single drug was positively associated with nocturnal BP decline. Later versus earlier morning dose time, but not once-a-day dosing, was associated with absence of dipping. Treated black and Hispanic hypertensives are less likely to "dip" than non-Hispanic whites. No particular drug was positively associated with dipping.

OBJECTIVES: Use of automated (electronic) blood pressure measurement devices to obtain clinic blood pressure measurements is becoming increasingly widespread in health care settings; their comparability with manual mercury sphygmomanometer readings is uncertain. Current guidelines for screening, diagnosis, and treatment of hypertension in clinical practice are based on clinical trials and epidemiological evidence derived from readings taken with auscultatory devices (usually mercury sphygmomanometers). This study was carried out to assess whether use of automated oscillometric devices in the clinical setting led to differences in classification of blood pressure levels at the 140 mm Hg systolic and 90 mm Hg diastolic thresholds compared to readings obtained with a standard mercury sphygmomanometer. DESIGN: We compared the blood pressure readings obtained with three automated devices that are widely available in the U.S. (one Dinamap Plus Model 8710 and two Dinamap Model 1846SX) and the readings taken by a single trained research assistant with a manual mercury column device in the emergency department and the outpatient medicine clinic of a large urban teaching hospital. The devices tested were those in normal use in the setting. The order in which the readings were taken was varied randomly. The sensitivity and specificity of the Dinamap readings compared to the mercury column device as the gold standard was calculated. RESULTS: The mean diastolic blood pressure in the three groups of patients studied was 7.3 mm Hg, 2.4 mm Hg, and 3.4 mm Hg lower with the Dinamap devices than the mercury column device (p is less than 0.001 for all comparisons). The mean systolic blood pressure readings were 1.0 mm Hg (p equals 0.06), 6.7 mm Hg (p is less than 0.001), and 4.2 mm Hg (p is less than 0.001) higher with the Dinamap device than the mercury column device. The difference between Dinamap and mercury column systolic blood pressure readings tended to increase at pressures greater than 140 mm Hg, whereas the diastolic blood pressure differences remained uniform throughout the blood pressure range. The sensitivity of the Dinamap readings compared to mercury column readings for classifying individuals as hypertensive was 73% for persons with elevated systolic blood pressure only, 51% for persons with both systolic and diastolic blood pressure elevation, and 10% for person with diastolic blood pressure elevation only. CONCLUSIONS: The Dinamap devices tested appeared to yield systematically biased blood pressure readings, which could alter the assessment of hypertension prevalence and control in clinical populations. Quality assurance and outcome researchers should attempt to document the type of device used to obtain blood pressure measurements noted in medical records, and be cognizant that small systematic errors in measurement could affect a setting's hypertension control performance. (c)2000 by Le Jacq Communications, Inc.

Background: The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people., Objectives: To describe the characteristics of abused or neglected patients and to compare the prevalence of depression and dementia in neglected patients with that of patients referred for other reasons., Design: A case control study., Setting: Baylor College of Medicine Geriatrics Clinic at the Harris County Hospital District (Houston, Texas)., Patients: Forty-seven older persons referred for neglect and 97 referred for other reasons., Intervention: Comprehensive geriatric assessment., Measurements: Standard geriatric assessment tools., Results: There was a statistically significant higher prevalence of depression (62% vs 12%) and dementia (51% vs 30%) in victims of self-neglect compared to patients referred for other reasons., Conclusions: This is the first primary data study that highlights a high prevalence of depression as well as dementia in mistreated older people. Geriatric clinicians should rule out elder neglect or abuse in their depressed or demented patients.