Office management of elderly hypertensive patients. Focusing on cognition and function.

OBJECTIVE: To review office management of elderly hypertensive patients and to focus on cognition and function both as ways to stratify who gets treated and as end points for treatment. QUALITY OF EVIDENCE: Relevant papers were identified through a MEDLINE search from January 1994 to March 2000, using the MeSH terms hypertension, aged, aged 80 and over, cognition, activities of daily living, therapeutics, hypotension orthostatic, and dementia. Many well conducted randomized controlled trials were found and are included. MAIN MESSAGE: Treatment of combined and systolic hypertension up to age 80 is clearly worthwhile; beyond age 85, other factors (chiefly cognitive and functional impairment) mitigate most routine recommendations. Successful treatment is individualized, taking into account comorbid conditions and their effect on cognition and function. Age is useful for thinking about groups, not individuals: as people age, risk of cognitive and functional impairment increases, but even very elderly people (> 85 years) with no impairment should be treated as younger patients are. Elderly people with signs of having a "brain at risk" should be managed with special vigilance. CONCLUSION: Good evidence supports treating elderly people, who are otherwise well and are cognitively and functionally intact, when their blood pressure is > 160 mm Hg systolic or > 105 mm Hg diastolic. There is insufficient evidence for carrying out routine recommendations for frail elderly people. Treatment of comorbid illnesses dictates choice of therapeutic agent.

Relationship between timed 'up and go' and gait time in an elderly orthopaedic rehabilitation population.

OBJECTIVE: To analyse the relationship between the timed 'up and go' (TUG) and gait time in an elderly orthopaedic population, in order to determine whether additional useful information is obtained by measuring both. DESIGN: Observational study. SETTING: Jewish Rehabilitation Hospital, Laval, Quebec. SUBJECTS: Seventy-nine consecutive inpatients in the orthopaedic programme with a primary admitting diagnosis of either total hip replacement (THR), total knee replacement (TKR), or hip fracture repair. OUTCOME MEASURES: Timed 'up and go' and time to walk 10 metres. RESULTS: The admission correlation between gait time and TUG was r= 0.745. The correlation at discharge (r= 0.816) was higher than that seen on admission. The relationship between gait time and TUG was linear both at admission and discharge. The correlation between gait time and TUG was strong for patients with TKR at admission (r= 0.868) and discharge (r= 0.878), and for patients with THR, both at admission (r= 0.809) and discharge (r= 0.879). However, the correlation on admission was weaker for patients with hip fracture (r= 0.497). For slow walkers (people with a gait speed below 0.5 m/s) on admission, the correlation was moderate (r= 0.649). However, for those with gait speeds faster than or equal to 0.5 m/s, the correlation was weaker (r= 0.484). This discrepancy was no longer evident on discharge. Likewise, for patients with a fast TUG score (< 30 seconds) on admission, there was virtually no relationship between TUG and gait time (r= 0.084), although a good correlation was present for those with 'up and go' times longer than 30 seconds (r = 0.634). As with gait speed, this difference disappeared by discharge. CONCLUSIONS: The relationship between gait time and TUG in an elderly orthopaedic rehabilitation population is good, and its strength varies by specific diagnosis, mobility, and time point in the course of therapy. The two measures are not redundant in this population.

Predictors of restful sleep in a rehabilitation hospital.

The effect of hypnotic use on self-rated quality of sleep and therapist-rated level of alertness was examined in an inpatient rehabilitation setting. We examined what other factors were predictive of a restful sleep in this population. Seventy-five inpatients at the Jewish Rehabilitation Hospital in Montreal were included. Patients were asked to rate the quality of their own sleep on a given night. Night nurses recorded whether sleeping pills had been used and rated patients' sleep and number of awakenings during the same night. Patients were evaluated by their physiotherapists and occupational therapists the next day regarding how well rested they seemed according to three parameters: alertness, fatigue, and level of participation in therapy. Thirty-three percent of the patients received sleeping pills on the study night. Sleeping pill use did not predict patient perception of getting a good night of sleep or the somewhat more objective sleep rating by the night nurse. Whether a sleeping pill was taken was also found not to be predictive of restful sleep as estimated by the physical and occupational therapists. Variables significantly associated with therapists' ratings of apparently restful sleep included number of comorbidities, the nurses' rating of how well the patient had slept, the patients' self-assessment of sleep, and whether the patient felt well rested the morning after sleep. However, the patients' own assessment of sleep quality was negatively related to their performance in rehabilitation therapy. This suggests that patient self-report of sleeping difficulty may not be the best or only guideline to follow when considering intervention such as prescribing sleeping pills, particularly because sleeping pill use seems not to influence either patient perception of sleep or how well rested they seem in therapy.