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The objective of this study, designed as a randomized controlled prospective intervention study, was to evaluate the effect of nutritional supplementation on functional status and need of care in undernourished geriatric patients during hospitalization, and up to 6 months after discharge. Participants consisted of 46 undernourished geriatric patients from a geriatric acute care hospital aged 75 years or older without malignant disease, or need for tube feeding or parenteral nutrition. Patients in the supplement group (SG, N = 20) were offered 400 mL (2100 kJ) daily of a liquid supplement during hospital stay and 200 mL (1050 kJ) per day for the following 6 months at home. Patients in the control group (CG, N = 26) had usual care without supplements. The main outcome measure was functional status based on the Barthel Activities of Daily Living score (ADL) at hospital admission, discharge and after 6 months, with higher scores indicating greater independence and a maximum score of 100 points. In supplemented patients with good acceptance (SG+, N = 11), a median improvement of 20 points was observed between admission and discharge, and a further improvement of 5 points at home. Median changes were 0 and -10 points in supplemented patients with poor acceptance (SG-, N = 9) and 5 and 2.5 points in CG, respectively. In SG+, the proportion of independent patients (> 65 points) increased continuously from 36% at admission to 63% at discharge, to 72% after 6 months, and was significantly higher compared to CG at discharge (63% vs 19%, p < 0.05) and after 6 months (72% vs 39%, p < 0.05). 64% of the patients in SG+ improved during hospitalization, compared to 23% in CG (p < 0.05). In the six months at home, 18% of SG+ improved; none of SG+ deteriorated in hospital or at home. In contrast, deterioration of the ADL score occurred in considerable proportions of SG- (22% in hospital, 22% at home) and CG (4% at hospital, 12% at home) patients. The proportion of patients who improved was smaller in SG- (44% at hospital, 22% at home) as well as in CG (23% at hospital, 35% at home), compared to SG+. In conclusion, a positive functional course was evident in supplemented patients with good acceptance during hospitalization, and further improvement was observed during the following 6 months at home. Nutritional support may contribute to reconvalescence and recovery of undernourished geriatric patients.

To determine predictors of death, nursing home placement and hospital admission, a prospective study was carried out in a university-affiliated geriatric hospital and a general practice. One hundred and thirty-five patients consecutively admitted from home to the geriatric hospital and discharged home again (site 1), and 144 patients, aged 70 years and over, of a general practice (site 2) were recruited for a comprehensive geriatric assessment program. At baseline, none was completely dependent on others, or severely demented. At follow-up after 18 months, 46 subjects (17%) had died, 20 subjects (7%) had been institutionalized, and 79 had been admitted to hospital (28 %) in the interim. Univariate analysis demonstrated a significant association between Barthel Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Balance and Gait Evaluation, Timed “Up and Go”, Timed Test of Money Counting, Grip-Strength and Williams Board Test, and death as well as nursing home placement. Barthel-ADL were significantly correlated with hospital admission. In a logistic regression analysis, Barthel-ADL were independent predictors for death; Barthel-ADL, Timed “Up and Go”, Timed Test of Money Counting, and Williams Board Test were independent predictors for nursing home placement. No independent predictor was found for hospital admission. It is concluded that self-report and performance-based measures of functional capabilities are useful instruments to identify patients at risk for nursing home placement and death. Factors contributing to hospital admissions are other than those measured by the applied tests.

Objectives: To examine medication problems during a stay in hospital and after discharge and to identify risk factors that contribute to poor compliance with medication a prospective observational study was carried out in an university-affiliated geriatic hospital and a patients' home. Patients: One hundred and nineteen patients admitted from home to the geriatric hospital underwent a comprehensive geriatric assessment. They were also tested in opening and removing tablets from various common medicine containers. Drug prescriptions before, during and after the hospital stay were recorded. Medication use at home was observed by a member of a hospital-based home intervention team. The patients' reports of their drug therapy was compared with those by their family doctors. Results: Of all tested patients 10.1% failed to open at least one container. This inability was associated with poor vision, impaired cognitive function and low manual dexterity. Compliance with prescribed medication was associated with cognitive function, ability to handle medication containers, number of prescribed drugs and recent changes in drug prescriptions. Of the patients only 39.5% had stable drug prescriptions during the 3-month study period. Doctor/patient agreement concerning drug therapy was low in all age groups. The agreement rate and patients' knowledge of their treatment was correlated with cognitive function and the number of prescribed drugs. Conclusion: Patients' ability to open and remove tablets from common commercial packages/containers should be tested routinely during a stay in hospital. Management of medication should be taught and supervised within the first few days after discharge from hospital.

The objective of the study was to compare compliance with and the hypocholesterolaemic effect of lovastatin given once daily as a morning or an evening dose. Twenty-four out-patients with familial hypercholesterolaemia were randomly assigned to receive placebo first, then lovastatin 20 mg, to be taken once daily for 4 weeks, either with the breakfast or evening meal, in a single-blind fashion. Drug compliance was assessed by pill counts and continuous electronic monitoring. Two compliance parameters were evaluated, consumption, defined as percentage of prescribed doses taken, and time compliance, the percentage of total dosing events recorded within defined intervals (6.00-10.00 h, and 17.00-21.00 h), for the morning and evening regimes. Both regimes satisfactorily reduced the total and LDL-cholesterol concentrations, and there was no significant difference in the extent of the reductions. Pill counts overestimated compliance, as revealed by the monitoring method. The times of actual consumption of doses by the patients often differed from that prescribed, predominantly in patients who were told to take the evening dose. Partial time compliance may have confounded the efficacy of the drugs. Electronic compliance monitoring appears to be particularly useful in chronopharmacological studies.

To obtain reference values for comparison with malnourished geriatric patients, the nutritional status of 50 apparently healthy women aged 75 or older living independently in two old people's homes in Heidelberg was examined. All women were able to walk, and were free from overt disease and signs of mental deterioration. Anthropometric measurements (body height and weight, triceps skinfold thickness, midarm circumference) and biochemical determinations of protein and vitamin status were performed. Anthropometric parameters were similar to those obtained in "younger" samples of healthy elderly, lower than those reported in younger adults, and markedly greater than those reported in geriatric patients. The majority of biochemical findings were within normal reference ranges established for healthy young adults. Only plasma retinol concentrations were below the reference limit in 8 women (16%). These findings show clearly that even in the very old, major alterations in biochemical indicators of nutritional status are rare. Neither advanced age nor institutionalization are associated with malnutrition. This obviously suggests that malnutrition in old age is mainly related to physical and mental disabilities.

A prospective drug surveillance study was undertaken in 300 elderly patients admitted to a geriatric clinic. Prescribing patterns were determined on admission, at discharge and 3.6 and 18 months after discharge. Patients referred from long-term care institutions were on significantly more drugs than non-institutionalized subjects. A 34% reduction in the number of medicines prescribed at discharge was accompanied by a significant decrease in the mean number of prescriptions per patient, from 4.3 to 2.8, irrespective of whether the patient was institutionalized. Polypharmacy, defined by 5 or more concomitant drugs, declined from 43 to 17%. Dosage schedules were simplified in the majority of patients, as expressed by a significant decrease in the mean number of daily doses to be taken from 6.7 on admission to 4.4 at discharge. Cardiovascular drugs, diuretics and psychotropic drugs accounted for 64% of all drug prescriptions. At discharge, prescription frequencies were reduced for most medication categories, except diuretics and gastrointestinal drugs, which were being taken more often. The prescribing frequency of cardiac glycosides, the single most frequently prescribed drug class, decreased from 60 to 33% of the patients. Three months after discharge, prescribing patterns and frequencies were found to be very similar to the pre-admission situation. Eighteen months after discharge, overall drug use had increased by 15% compared to admission, and polypharmacy was recorded in 54% of patients. It is concluded that a substantial reduction in drug prescriptions was possible in the majority of elderly patients, particularly if they are institutionalized, on admission to a geriatric clinic.(ABSTRACT TRUNCATED AT 250 WORDS)

The review of medication has been recommended as an important part in preventing falls. In a random sample of 276 hospital in-patients aged 75 and over, the frequency of prescribed drugs which may increase the risk of falling by causing dizziness was assessed. Questions about dizziness and previous falls were included in a standardized questionnaire. Patients with dizziness reported falls 10 times more often than patients without dizziness. Prescribed medications possibly causing dizziness were very common. Neuroleptics, antidepressants, hypnotics/sedatives, and combinations of drugs with hypotensive efficacy were significantly more often prescribed in patients who reported dizziness. Systematical review of medications appears to be worthwhile, particularly in cases with multiple drug prescriptions.

Every geriatric patient should routinely be questioned about possible urinary incontinence. The basic diagnostic work-up comprises the clinical history, wherever indicated a geriatric assessment, a nursing care history, a physical examination and a micturition protocol. Furthermore, determination of postvoid residual urine, laboratory investigations and a urine-analysis should be done in all patients. Ultrasonography of the urinary tract is a simple non-invasive procedure that can exclude the presence of large tumors, stones in the bladder and urinary retention. Only selected patients require a greater diagnostic effort prior to treatment, for example, urologic and/or gynecologic investigations or a urodynamic evaluation.

The therapeutic strategy rests on a simple basic diagnostic investigation. As a rule, the greatest importance attaches to toilet training and individual counseling. In this context, the work of a specialist nurse capable of providing both the patient and his/her relatives with competent instruction is of considerable importance. A greater diagnostic effort is needed only for selected prior to the initiation of therapy. Even in the elderly patient urinary incontinence is curable or can at least be improved; it is not an inevitability of old age.

This randomized study was performed to assess the effects of3 hours of physical exercise per week and low-fat diet on collateral formation in nonselected patients with coronary artery disease (intervention group, n = 56). Results were compared with those of patients in a control group (n = 57), who received usual care by their private physicians. Coronary lesions were assessed by quantitative coronary angiography at the beginning and after 1 year of study (n = 92). As previously reported, after 1 year there was a significant retardation of progression of coronary artery disease in the intervention group as compared with the control group. In this study, evaluation of collateral formation revealed no significant difference between both groups, and changes in hemodynamic and metabolic variables or leisure time physical activity were not related to changes in collateral formation. Although progression of the disease was significantly related to an increase in collateral formation, regression was significantly related to a decrease in collateral formation (p0.00001). Because patients in the intervention group exercised for3 hours/week, and patients with regression of coronary artery disease even dedicated 5 to 6 hours to leisure time physical activity per week, these findings question whether an exercise program within the safety tolerance of patients will be able to induce coronary collateralization in the presence of regression of coronary artery disease.

The purpose of this prospective study was to measure patients’ ability to open a purse, take out money, and count it, in order to identify persons in need of increased health care. The study population consisted of 183 patients (mean age 78.9; range: 66-95) in two settings: 78 consecutively admitted geriatric hospital patients who could return home, and 105 community-dwelling patients aged 70 years or older. None was completely dependent on others, nor severely demented. Time for task performance was measured. Further assessment included the Mini-mental State Examination (MMSE), Barthel index of ADL, instrumental activities of daily living (IADL), socioeconomic status, grip strength, Williams board test, and medication profile. The Timed Test of Money Counting (TTMC) was reliable (interrater and intrarater), and showed construct and concurrent validity with other measures of physical function. There was a strong correlation (p

The transition team has its place in pre- and postdischarge nursing and therapeutic care, on the basis of a geriatric assessment. Core members of the team are, in the sequence of the scheduled performance in-hospital, nurse, occupational therapist, physiotherapist and social worker, supplemented by a team physician. Two-thirds of all treatments were in the hospital, one-third in an outpatient setting up to 4 weeks after discharge. Cooperation with outpatient services has been good.

Psychiatric diseases are very common among elderly people. Depressions rank before dementias in this age group. 2-2.5 million people aged over 65 years are suffering from symptoms of depression in Germany. Patients with Mayor Depression Disease (MDD) have a poor prognosis. MDD should therefore be recognized and treated in community dwelling elderly, in nursing homes and in hospitals. Underdiagnosis of MDD is well documented in the medical literature. Only a quarter of patients with a MDD are detected. By a short screening test for depression such as the Geriatric Depression Scale (GDS) depressed patients can be identified. With a sensitivity and specificity of about 70%. The time needed to perform the short form of the GDS is only 5-7 min. The GDS is an important part of many assessment programs in England and USA. It is also recommended in Germany by the "Geriatric Assessment" working group.

To evaluate functional disabilities in elderly patients, geriatric assessment was performed in one general practice. Excluded from the study were patients with severe dementia and dependence. 178 patients were asked to participate and 144 accepted (mean age 78.7 +/- 5.8 years; number of diagnoses 5.2 +/- 2.6; f = 95, m = 49). Mini-mental-status examination showed moderately but significantly lower (p0.05) cognitive capacity in the age groups of 80-84 years (n = 37, 24.56 +/- 4.90 points) and of 85 years and older (n = 30, 25.14 +/- 3.11 points), but not in the group of 75-79 years (n = 46, 26.70 +/- 3.90 points) compared to the group of 70-74 years (n = 31, 27.65 +/- 2.59 points). Neither the Geriatric Depression Scale nor the Barthel-Index (activities of daily living) showed significant differences between the age groups. The score of the instrumental activities of daily living (Lawton Index) was significantly lower (p0.05) in the age group 85 years and older (4.1 +/- 2.5 points) compared to the age group of 70-74 years (6.1 +/- 2.4 points). Grip strength was significantly reduced (p0.01) in the age group 85 years and older as well as motility and balance scores (Tinetti test; p0.05) compared to the group of 70-74 years (43.21 +/- 16.27 kp and 64.87 +/- 19.81 kp, resp., 19.3 +/- 6.6 and 23.1 +/- 5.9 points). No correlation was found between the results of functional assessment and number of contacts with the general practitioner in the past year, number of prescribed drugs and number of diagnoses except for the depression test. There was a significant correlation between test score, number of contacts, and number of diagnoses (p0.05). Functional assessment resulted in new diagnoses of urinary incontinence in 7 patients and of mobility disorders in 17 patients. Cognitive impairment was suspected in 14 patients, depression in 2 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

To evaluate social aspects of elderly patients which are important for diagnosis and therapy within geriatric assessment, a questionnaire was developed and validated. Raters showed a high degree of agreement on the scale, which contains social contacts and support, activities, economic situation, and housing conditions (0.92-0.97; p0.05). Compared to the interrater reliability the test-retest reliability was somewhat lower (0.75), but also significant at the 5% level. The internal consistency showed high values between 0.72-0.89. In order to evaluate the validity of the screening test the answers of the patients were compared with the assessment of the therapeutic team. The team had information from a home visit, patients spouse, relatives, neighbors, community nurses and/or general practitioners. There was a significant relationship (p0.01) between therapeutic assessment and the scale (r = 0.51). Sensitivity, specificity, and total efficiency also attained sufficiently high values at a cut-off of 16/17 for the complete scale (max. 25 points). The test is easily and quickly performed; its acceptance is high. Social data relevant for treatment and discharge planning can thus be obtained and patients can be identified, for whom a home visit seems to be useful.

The causes of early rehospitalization (within 3 weeks) of very elderly patients, its possible avoidance and appropriate preventive measures were analysed retrospectively in patients of a geriatric hospital. Included were all those patients who had been admitted to the hospital from their home several (mean: five) times between 1987 and 1990 (48 women, 19 men; mean age 81.3 +/- 7.2 years--a total of 331 re-admissions). The most frequent diagnoses were heart failure (38.8%), acute cerebrovascular accident or its sequelae (31.3%), dementia (23.9%), fall or its sequelae (22.3%) and diabetes (20.9%). Of the 331 re-admissions 87 (26.3%) occurred during the first 3 weeks after discharge. The most important reasons of this early re-admissions were inadequate home care (41.4%), undesirable drug effects and non-compliance (25.3%), as well as rapid progression of the basic disease (14.9%). In the judgement of the hospital team more than 40% of the early re-admissions were avoidable, among those re-admitted because of inadequate home care and those in connection with drug intake even more than half. Early hospitalization is frequently avoidable, if individual geriatric assessment is undertaken and discharge carefully planned.

One of the nutritional problems in elderly people is undernutrition, which is multifactorial in origin: The causes cannot only be seen in poor nutrition. Physical handicaps such as problems with chewing and swallowing, difficulties to cut food, immobility and mental restrictions are responsible for reduced food intake and malnutrition. Psychic and socio-economic problems such as depression, life events and loneliness may reduce appetite; poverty also contributes to the risk of undernutrition. As a result of our investigations of 300 geriatric patients, physical handicaps with influence on nutrient intake such as immobility or chewing problems were found in nearly 50% of all cases; undernutrition was observed in 22% of the patient group. In a group of 50 apparently healthy women aged 75 or older, the frequency of risk factors as well as the frequency of malnutrition was remarkably lower. These results confirm the thesis that, in most of the cases, undernutrition is related to medical problems and to the simultaneous presence of several of the above-mentioned risk factors. As a conclusion, treatment and prevention of malnutrition have to consider individually the elderly person's complete life situation. Present risk factors have to be removed, if possible; even better would be to avoid them.

The starvation diet has become a widely adopted method of treating obesity. Unfortunately, it leads to occasionally serious complications in about 8% of the patients thus treated.15 There is consequently an urgent need for systematic analyses of the metabolic changes occurring in the course of such cures. Hitherto, influence of fasting on the plasma microprotein spectrum has not been studied to any great extent. In a series of patients treated by Fateh, a decrease in the serum concentrations of C3, transferrin, and haptoglobin and a slight increase in the plasma concentrations of IgA and IgM were observed during treatment; the coeruloplasmin levels had already been elevated at the beginning of fasting. The serum concentrations of total protein, albumin, α2-macroglobulin, IgG, IgE, and α1-foetoprotein were not significantly affected by starvation.4 By contrast, Ditschuneit had the impression that the concentrations of IgA, IgG, IgM, C3, albumin, and total protein decreased.3 In view of these partially contradictory results and of the limited spectrum of individual proteins analyzed, we determined the following protein components of the plasma in a series of 12 obese patients who were placed on a starvation diet for a period of 4 wk: total protein, albumin, α2-macroglobulin, transferrin, haptoglobin, coeruloplasmin, prealbumin, retinol-binding protein, α2-HS-Glycoprotein, acid α1-glycoprotein, Gc-globulin, β2-microglobulin, IgG, IgM, IgA, Clq, C3, C3-activator, C4, and properdin. In addition, since proteinuria is known to occur in rats as a result of starvation,21 we measured the urinary concentrations of the proteins characteristic of glomerular proteinuria, i.e., α2-macroglobulin, transferrin, haptoglobin, and albumin, and of those indicative of tubular damage, i.e., prealbumin, α2-HS-glycoprotein, acid α1-glycoprotein, and Gc-globulin.

During 4 weeks, 40 obese subjects (body mass index 30-45 W/H2) were treated with a 300-kcal mixed diet alone or in combination with exercise training on a bicycle ergometer in a metabolic ward. Exercise had a minor effect on body weight, reflected by an additional fat loss of 1.7 kg (expected loss: 4.0 kg). Hyperinsulinemia was improved by diet and normalized by diet combined with exercise; a similar effect was observed regarding C-peptide levels. Plasma concentrations of epinephrine and norepinephrine decreased in both groups. At maximal work, norepinephrine levels were higher in the group with exercise. Free fatty acids and free glycerol increased at rest as well as during exercise in subjects on both regimens, the difference being more pronounced in the exercise group. Enhanced oxidation of fat was substantiated by lower respiratory quotients during endurance exercise. Working capacity increased and blood pressure decreased considerably as a consequence of physical training. It is concluded that exercise training in addition to a hypocaloric diet lowers body weight and body fat, although to a lower degree than expected. During and following bouts of exercise, fat mobilization and oxidation is enhanced, but these effects are probably counteracted at rest. On the other hand, the diet-induced deterioration of physical performance is overcompensated.

The effect of guar (15.6 g/day), a dietary fibre, and simultaneous administration of bezafibrate (600 mg/day) during dietetic treatment on the plasma lipoproteins and apolipoproteins was investigated in 12 patients with familial hypercholesterolemia (corresponding to the HLP type IIa pattern). Either bezafibrate alone or bezafibrate in combination with guar was administered in a cross-over study for 3 months. Guar led to an additional lowering of the total cholesterol in the plasma by 7% (P less than or equal to 0.05) associated with a fall of the low density lipoprotein cholesterol (LDL-cholesterol (LDL-cholesterol) by 13% (P less than or equal to 0.01) without any changes in the very low density lipoprotein (VLDL) and high density lipoprotein (HDL) cholesterols. In parallel with the decrease in LDL-cholesterol, the apoprotein B also was diminished by 20% (P less than or equal to 0.05). The plasma triglyceride level and the triglyceride distribution within the individual lipoprotein fractions were not altered in any consistent manner by the addition of guar. Neither the fasting plasma glucose level nor the body weight were affected. The side-effects due to guar treatment consisted of slight nausea, meteorism and constipation, but this did not in any of the cases lead to early termination of the study. These results demonstrate that guar exerts its cholesterol-lowering effect in addition to that of bezafibrate.

The influence of a new hypolipidaemic agent, bezafibrate, on anticoagulant requirements and fibrinolysis was studied in 15 patients with hyperlipidaemia on long-term treatment with racemic phenprocoumon. Our results suggest a dose-dependent augmentation of the anticoagulant response to the coumarin drug. Treatment with bezafibrate at 450 and 600 mg daily required a reduction of the phenprocoumon dose by 18.5 and 33.5%, respectively. Correspondingly, the serum level of phenprocoumon decreased by 11.6 and 35.3%. No evidence for an altered drug elimination of racemic phenprocoumon could be found during treatment with bezafibrate. The results support the hypothesis that bezafibrate and analogous hypolipidaemic drugs enhance the response to oral anticoagulant drugs by increasing the affinity of the receptor site for coumarins or the rate of degradation of the vitamin-K-dependent clotting factors. The investigation of the fibrinolytic enzyme system demonstrated an increase of the fibrinolytic activity by enhancing the activity of the plasminogen activator. The lysis time for euglobulin clot was reduced significantly, plasma fibrinogen only moderately. The antiplasmin activity could not be altered substantially by a decrease of al-antitrypsin and a slight increase of α 2 -macroglobulin. In contrast with the inhibition of platelet function the effect of bezafibrate on the fibrinolytic enzyme system showed no dose dependence.

The effect of nicotinic acid and several derivatives on the nocturnal level of free fatty acids was studied in 12 healthy young women and men. Free fatty acids are an important precursor of plasma triglycerides and their concentration is highest at night. The drugs used were nictinic acid, beta-pyridyl-carbinol, mesoinositol hexanicotinate and xantinol nicotinate. The highest plasma nicotinic acid level was observed with beta-pyridyl-carbinol, but significant reduction in free fatty acids during the entire night was only achieved with inositolhexanicotinate and xantinol nicotinate. There was no correlation between the plasm levels of free fatty acids and nicotinic acid at any sampling time. If prolonged reduction in free fatty acid concentration is desired in the therapy of hyperlipidemias, the inositol and xantinol esters of nicotinic acid appear to be superior to the other preparations.

Controlled dietary studies with formula diets in normal subjects and in patients with type IV hyperglyceridemia were performed, comparing high fat (65% of total calories) with high carbohydrate (80% of total calories) diets. In spite of ‘carbohydrate-accentuation’ on the latter diet, as judged from fasting triglyceride values, all-day triglyceride levels were higher with 65% fat formula, particularly in the patient group. Since all-day free fatty acid levels showed similar behaviour, it is suggested that control of endogenous hyperlipidemia may require a properly balanced diet rather than extreme carbohydrate restriction and fat supplementation.

Previous studies have shown that carbohydrate induction of hypertriglyceridemia in normal subjects occurs at night and appears to be related to a rise of free fatty acids after diurnal feeding of high-carbohydrate formula diet. The present investigation was undertaken to observe the effect on 24-h triglyceride, free fatty acid, blood sugar, and plasma insulin profiles of inhibition of nocturnal lipolysis by glucose or nicotinic acid in normal subjects and in patients with type IV hyperlipoproteinemia. In 10 normal subjects and 10 patients with primary type IV hyperlipoproteinemia, plasma triglyceride, free fatty acid, blood sugar, and insulin levels were followed in short intervals for 24 h while a 2,400 cal, 80% carbohydrate, fat-free formula diet was given in six equal portions during the day (control experiments). This procedure was repeated in the same subjects, 10 of whom (5 normal subjects and 5 patients) received additional feedings of glucose between 2000 and 0600 h while the other 10 persons (5 normal subjects and 5 patients) were given nicotinic acid by intravenous infusion during the same time interval. Both procedures resulted in maintained lowering of free fatty acid levels over 24 h. Mitigation of carbohydrate-induced hypertriglyceridemia appeared to result from the additional glucose in normals and in patients. Nicotinic acid abolished the nocturnal rise of plasma triglyceride levels which in the control studies of normal subjects had resulted in approximate doubling of triglyceride levels in 24 h. The effectiveness of nicotinic acid in inhibiting nocturnal lipolysis and preventing carbohydrate-induction of hypertriglyceridemia might have consequences for management of endogenous hypertriglyceridemia.

Diurnal patterns of plasma triglycerides, free fatty acids, blood sugar and insulin were studied in 6 normal subjects and in 6 patients with the type IV hyperlipoproteinemia in order to assess the effect of a formula diet of balanced composition(19% protein, 37% fat, 44% carbohydrate) and of frequency of meal intake (3 versus 6 meals). In addition, the endogenous component of alimentary lipemia was estimated for the 24-hour period. The results demonstrate, that all-day levels of nutrients and insulin are similar with both meal patterns and that, regardless of feeding frequency, a considerable portion of ‘alimentary lipemia’ is contributed by pre-beta lipoprotein triglycerides.

Because the incidence of venous thromboembolism, coronary heart disease, and stroke is increased in users of oral contraceptives (OCs), the possible causal metabolic side effects of OCs have been widely investigated. In this article we present epidemiologic data associated with OC use. Total plasma triglycerides and cholesterol levels were elevated in OC users while high-density lipoprotein cholesterol levels were lowered. Another section discusses some hormone-dependent physiologic and pathophysiologic aspects of lipid metabolism. Finally, we report on the isolated influence of estrogens and progestogens and their interrelation, including some recent findings about the effects of different progestogens on lipoproteins.The incidence of venous thromboembolism, coronary heart disease, and stroke is increased in users of oral contraceptives (OCs). This article presents epidemiologic data associated with OC use. In a health and nutrition survey of 800 women (20-40 years of age) from Heidelberg, West Germany, fasting blood values, 24-hour urine values, blood pressure readings, fat biopsies, and data on nutritional and medication intakes were recorded. Comparisons were made between current OC users, former users, and those who had never used the pill. Total plasma triglycerides and cholesterol levels were elevated in OC users while high density lipoprotein cholesterol levels were elevated in OC users while high density lipoprotein cholesterol levels were lowered. The epidemiologic experience with users of OCs showed an association between the estrogen content of the pill and venous thromboembolism; therefore, the estrogen dose was lowered. In the low-estrogen OC, significant positive correlations of arterial disease and hypertension with the progestogens content of the pill were noted. There are differences between effects of exogenous and endogenous gonadal hormones in men and women and between single or combined treatment with estrogens and progestogens. Beneficial effects on some lipoproteins can possibly be elicited with certain progestogens. Postmenopausal women might profit from estrogen therapy.

The influence of prolonged energy restriction (1250 kJ for 4 weeks) on insulin's antilipolytic action was investigated in abdominal adipocytes of obese subjects. An attempt was made to discriminate between dietary influences per se and indirect influences caused by changes in the concentration or action of adenosine. Prolonged energy restriction resulted in about a 3.5-fold increase in basal lipolytic rate which was associated with a corresponding increase in maximal response to insulin. Both these effects could be mimicked by adenosine deaminase (1.6 micrograms/ml) which increased glycerol release of adipocytes from fed donors to levels normally seen during starvation suggesting that the improvement of lipolytic responsiveness to insulin during energy restriction was an apparent one only, due to the fact that glycerol release was increased. To identify dietary influences that selectively affect insulin action the effects of insulin were compared with those of other antilipolytic agents in the presence of adenosine deaminase. Maximally effective concentrations of prostaglandin E2, clonidine and N6-phenylisopropyladenosine almost completely suppressed glycerol release before and during starvation. The extent of inhibition produced by these latter compounds was therefore related to basal activity by the same linear relationship in all experimental settings. By contrast insulin only partially depressed glycerol release and the relationships between basal activity and response to maximal concentrations of insulin were significantly different before and during starvation (P less than or equal to 0.01) in the presence of adenosine deaminase indicating that starvation selectively influences insulin action via mechanisms that are unrelated to the effects of other antilipolytic compounds. It is concluded that the main effect of energy restriction on insulin's antilipolytic action is an apparent one which is secondary increased lipolytic activity. Direct dietary effects on insulin action became apparent upon removal of endogenous adenosine. These tend to limit the maximal response to insulin and may be due to changes at the post-binding level but could also reflect an intrinsic property of insulin's antilipolytic action.

The effect of beta-sitosterol on the lipid and lipoprotein level was evaluated in a randomised double-blind cross-over trial in 24 patients with primary familial type II hyperlipoproteinaemia over a period of 16 weeks. All patients completed the trial, however 10 of them had to be excluded from the evaluation due to fluctuations of their body weight or unreliable drug intake. Sitosterol lowered the total cholesterol level by 12.5% (P less than 0.01) from 9.96 mmol/l (3.69 g/l) to 8.37 mmol/l (3.23 g/l). The LDL-cholesterol level was lowered by 19.5% (P less than 0.05). The sitosterol concentration in plasma was consistently lower than 0.3% of total cholesterol. No side effects or tachyphylaxis was observed in the course of the trial. A return to normal of an increased serum cholesterol level by a combination of a lipid lowering diet and sitosterol monotherapy was only achieved in one patient.

The effects of adrenaline, noradrenaline, and of the alpha 2- and beta-selective agonists clonidine and isoproterenol were studied in fifteen obese subjects before and after 4 weeks of caloric restriction (300 cal day-1). Basal glycerol release averaged 1.4 mumol (10(6) cells)-1 (180 min)-1 before starvation and 2.8 mumol (10(6) cells)-1 (180 min)-1 during starvation (P less than or equal to 0.1). Before starvation adrenaline and noradrenaline caused a 2-3-fold increase of glycerol release. This lipolytic effect disappeared during starvation. An inhibitory effect of adrenaline was observed instead which was maximal at an adrenaline concentration of 1 mumol 1(-1) (P less than or equal to 0.05). The dose-response relationships of the alpha 2- and beta-selective agents clonidine and isoproterenol were not appreciably changed by caloric restriction. The increase of basal lipolytic rate and the reversal of adrenaline action seen during caloric restriction could be mimicked by removal of endogenous adenosine using adenosine deaminase (1.6 microgram ml-1). In addition, inclusion of N6-phenylisopropyladenosine (1 mumol 1(-1)) into the medium reverted the adrenaline-induced inhibition seen during caloric restriction. The results suggest that local modulators such as adenosine are of primary importance for the apparent change of responsiveness to adrenaline and noradrenaline seen during starvation of human fat cells in vitro.

Among 196 patients with a mean age of 80 years there were, at the time of hospitalization, 12.2% who had been prescribed wrong or partly even high-risk medication drugs, some of which carried a high risk. Among 694 prescriptions 4.2% were faulty. The faults consisted of failure to take account of impaired renal function, contraindications, accompanying illnesses, and misinterpretation of side-effects. 80% of these prescriptions were for diuretics, psychoactive and antiarrhythmic drugs, digitalis and hypnotics. The number of faulty prescriptions on discharge was 1.4%. In all, the average number of prescribed drugs had decreased from 3.5 on admission to 2.9 on discharge. This retrospective study demonstrates that the manner of prescribing for elderly patients needs to be handled more critically and rationally.

The effect of adrenaline on adenylate cyclase activity in membranes prepared from human abdominal and gluteal adipose tissue was examined. Basal enzyme activity averaged 1.0 nmol cAMP/mg protein/15 min in abdominal tissue and 0.68 nmol cAMP/mg protein/15 min in ghosts from the buttock. Maximally effective concentrations of sodium fluoride (20 mmol/l) induced an eight-fold increase in both membrane preparations. The maximal response to adrenaline (1.0 mmol/l) averaged 170% in ghosts of abdominal tissue compared with 60% in gluteal membranes. The concentrations of adrenaline required to produce half-maximal stimulation were similar in membrane preparations of both regions (about 5 × 10-5 mol/l).

The differential effect of two diets, taken in synchrony with the menstrual cycles for 2 wk each,on serum and bilelipidswas investigated inyoung healthywomen. The "normal" diet was high in cholesterol and total fat, and low in polyunsaturated fat and fiber, the "prudent" diet contained a high proportion of polyunsaturated fat and fiber, but was low in cholesterol and total fat; there was little difference inenergycontent. Both in whole serum and in low-density lipoprotein the concentrations of cholesterol and apolipoprotein B were almost 30% lower with the "prudent" than with the "normal" diet; HDL-cholesterol was 16.3% lower. Triglycerides were increased, only in the very-low-density lipoproteins while cholesterol and apolipoprotein B did not change much in this fraction. The risk to acquire cholesterol gallstones was not less with the use of the "prudent" diet as originally expected. While using the "prudent" diet five of the women had slightly higher lithogenic indices, in two there were much higher values (>25%), and only in three the lithogenic index was unchanged or slightly lower than with the "normal" diet. Am J ClinNuir 1985:42:1201-1205.

The efficacy of a fat-modified, low-cholesterol diet was studied in 38 children and adolescents with familial hypercholesterolemia on an out-patient basis, and the results compared with those achieved with dietary treatment in hospital. On an out-patient basis, a 10% reduction of plasma cholesterol levels was achieved and maintained. However, no patient showed normalization of plasma cholesterol levels. During hospitalisation, the mean plasma cholesterol levels fell by 24%, beta-cholesterol levels by 27%. This resulted in normal plasma lipids in almost half of the patients. Our results demonstrate the efficacy of intensive dietary management in children and adolescents with familial hypercholesterolemia. Long-term results on an out-patient basis could probably be improved by early nutrition education and an improved supply of suitable dietary foods.

Demographic developments in the Federal Republic of Germany indicate a future marked increase in the aged population. With this, there will be an increase in elderly patients. Malnutrition can contribute to disease as well as result from it. While most urgent nutritional problems of the population in general reside in the areas of increased intakes of energy and certain nutrients, nutritional deficiencies are frequent in older citizens, and in particular, geriatric patients. These deficiencies may result from psycho-social factors such as isolation, depression, or chronic brain failure, as well as from clinical factors (diseases which increase nutritional requirements or utilization of nutrients, drug/nutrient-interactions, etc.). The following questions are addressed: 1) How frequent is malnutrition in geriatric patients and which forms of malnutrition can be found? 2) What are the causes of malnutrition? 3) What is the relationship between malnutrition and mortality? 4) Which strategies for prevention and treatment of malnutrition can be developed from the above findings? The study is performed in Bethanien-Hospital, Heidelberg, FRG, a geriatric hospital and day clinic. Three hundred patients aged 75 years or older (representative sample) were included. Nutrition and nutritional status are determined and related to health, drug therapy and other psycho-social conditions in the very old. The prospective part of the study is planned for 18 months and this will also be the duration of the intervention phase.

10 patients with primary, endogenous hypertriglyceridemia (type IV hyperlipoproteinemia) underwent three different isocaloric dietary regimes of 10 days duration each. The diets contained either 30, 43 or 79% of calories as carbohydrate with 20% of calories from protein. Analyses of insulin, blood sugar and free fatty acids were conducted on the last day of each dietary period, at frequent intervals. There were no differences in either fasting or diurnal blood sugars with the different diets. Insulin levels were positively correlated with the amount of carbohydrate in the diet and there was an inverse correlation between the carbohydrate contents of the diets and circulating free fatty acid levels during waking hours. Since glucose tolerance is maintained, and diurnal plasma lipid levels are lowest with the low fat regime, such diets may be advantageously used for patients with endogenous hypertriglyceridemia.

The antilipolytic effects of N6-phenylisopropyladenosine and of prostaglandin E2 were studied with adipocytes of obese volunteers before and after 4 weeks of severe energy restriction [1250 kJ (300 cal)/day] in the presence and absence of adenosine deaminase (1.6 micrograms/ml, corresponding to 320 m-units/ml). The studies were undertaken to define more clearly the role that local modulators might play in adaptation of lipid mobilization to starvation in humans. Starvation was associated with an approx. 3-fold increase in non-stimulated lipolysis. Removal of endogenous adenosine resulted in a similar increase in basal glycerol release under both conditions, averaging 2 and 2.2 mumol/180 min per 10(6) cells respectively. The sensitivity of the cells to N6-phenylisopropyladenosine and to prostaglandin E2 was not changed by starvation in the presence of adenosine deaminase. These results are discussed in terms of the possible role that local regulators might play during dietary adaption in human fat-cells in vitro.

10 patients with primary, endogenous hypertriglyceridemia (type IV hyperlipoproteinemia) underwent three different isocaloric dietary regimes of 10 days duration each. The diets contained either 30, 43 or 79% of calories as carbohydrate with 20% of calories from protein. Analyses of insulin, blood sugar and free fatty acids were conducted on the last day of each dietary period, at frequent intervals. There were no differences in either fasting or diurnal blood sugars with the different diets. Insulin levels were positively correlated with the amount of carbohydrate in the diet and there was an inverse correlation between the carbohydrate contents of the diets and circulating free fatty acid levels during waking hours. Since glucose tolerance is maintained, and diurnal plasma lipid levels are lowest with the low fat regime, such diets may be advantageously used for patients with endogenous hypertriglyceridemia.

Plasma phosphate (Pi) and several indices of Ca-Pi metabolism were measured in 129 randomly selected healthy female individuals of the general population, of whom 59 were on hormonal contraceptives and 70 were not. Fasting plasma Pi was significant (p less than 0.01) lower in those taking hormonal contraceptives (0.96 +/- 0.17 mmol/l) than in those not taking them (1.06 +/- 0.16). Those on hormonal contraceptives had identical age, body weight and UVcr. Systolic and diastolic blood pressure was higher in those on hormonal contraceptives, and there was an inverse relationship between blood pressure and plasma Pi. Between those on hormonal contraceptives and those not on them, no significant difference of urinary cAMP (non-hormone 4.69 +/- 1.48 nmol/l GF; hormone 4.43 +/- 1.18) or iPTH could be shown. The present study documents that hormonal contraceptives with estrogen (less than or equal to microgram/dl) decrease plasma Pi and urinary Ca in premenopausal nonosteoporotic women.