Psychiatric symptoms of dementia: Treatable, but no silver bullet.

Behavioral problems are common in dementia and may reduce the quality of life of the patient and disrupt the home life of family members. Families want a pill that can cure the myriad phenotypes of a decaying brain; unfortunately, there is no pharmaceutical silver bullet. This paper reviews the evidence for using different classes of drugs for the behavior symptoms commonly encountered in dementia, focusing on concerns that the primary care physician would have about using these drugs.

Prevalence of hypertension and pre-hypertension among adolescents.

OBJECTIVE: To determine the prevalence of hypertension and pre-hypertension on the basis of the 2004 National High Blood Pressure Education Program Working Group guidelines in an adolescent school-screening population. STUDY DESIGN: Cross-sectional assessment of blood pressure (BP) in 6790 adolescents (11-17 years) in Houston schools was conducted from 2003 to 2005. Initial measurements included height, weight, and 4 oscillometric BP readings. Repeat measurements were obtained on 2 subsequent occasions in students with persistently elevated BP. Final prevalence was adjusted for loss to follow-up and logistic regression used to assess risk factors. RESULTS: BP distribution at initial screen was 81.1% normal, 9.5% pre-hypertension, and 9.4% hypertension (8.4% Stage 1; 1% Stage 2). Prevalence after 3 screenings was 81.1% normal, 15.7% pre-hypertension, and 3.2% hypertension (2.6% Stage 1; 0.6% Stage 2). Hypertension and pre-hypertension increased with increasing body mass index. Sex, race, and classification as either at-risk for overweight or overweight were independently associated with pre-hypertension. Only classification as overweight was associated with hypertension. CONCLUSIONS: Application of new classification guidelines for adolescents with elevated BP reveals approximately 20% are at risk for hypertension. Further research determining the significance of each BP category and refining definitions to account for BP variability is warranted.

Effect of stimulants on 24-h ambulatory blood pressure in children with ADHD: a double-blind, randomized, cross-over trial.

Millions of children with attention deficit hyperactivity disorder (ADHD) are treated with stimulant medications. To evaluate cardiovascular risk, 24-h ambulatory blood pressure monitoring (ABPM) was performed on and off medication. Thirteen subjects underwent APBM both on stimulant therapy and placebo using a placebo-controlled, double-blind, randomized, cross-over design. After a 3-day run-in followed by a 24-h monitoring period, subjects crossed over to the alternate therapy for repeated ABPM. Subjects demonstrated elevations in most hemodynamic parameters derived from ABPM during the active treatment period. Total diastolic blood pressure (69.7 mmHg vs 65.8 mmHg, p =0.02) and waking diastolic blood pressure (75.5 mmHg vs 72.3 mmHg, p =0.03) were significantly higher during active treatment. Total heart rate was also significantly higher during active treatment (85.5 beats/min vs 79.9 beats/min, p =0.004). The rate-pressure product (the product of systolic blood pressure x heart rate), an index of myocardial oxygen demand, was higher during active treatment (9,958 vs 9,076, p =0.008). This study provides evidence for a possible negative cardiovascular effect of stimulant medications in children with ADHD. This potential cardiovascular risk should be balanced against the beneficial behavioral effects of this class of medication.

Characteristics of hypertensive children identified by primary care referral compared with school-based screening.

OBJECTIVES: To determine whether there are clinical differences between children referred for hypertension evaluation from a primary care practice and children with hypertension detected through school-based screening. Study design Referral patients (n=58) were compared with 44 screening patients with hypertension from school-based screening of 5102 students. All subjects underwent 24-hour ambulatory blood pressure (BP) monitoring. White coat hypertension was defined as 24-hour mean BP <95th percentile and BP load <25%. RESULTS: Referral subjects were more likely to be male and had higher body mass index than screening subjects but did not differ by age or ethnic distribution. Average clinic BP values tended to be higher among referral patients (140/79 vs 135/76 mm Hg, P=.07); however, the hypertension severity was closely matched when clinic BP was indexed to the subject-specific 95th percentile. Ambulatory mean BP, BP indices, and BP loads showed no differences by subject source for 24-hour, wake, or sleep periods. White coat hypertension prevalence did not differ between referral and screening subjects (28% vs 30%, P=.83). CONCLUSION: These findings suggest that hypertensive children identified by subspecialty referral are representative of the overall population of hypertensive children in the community, thereby supporting the generalizability of clinic-based research in pediatric hypertension.

Isolated systolic hypertension, obesity, and hyperkinetic hemodynamic states in children.

OBJECTIVE: To determine the factors that contribute to the pathogenesis of isolated systolic hypertension in children. METHODS: School-based measurement was performed of blood pressure (BP), heart rate, weight, and height in 2460 students (49% Hispanic, 31% black, 13% white) 12 to 16 years of age in 8 urban public schools. An independent group of 71 untreated children underwent 24-hour ambulatory BP monitoring (ABPM) to confirm clinic hypertension and assess circadian BP patterns. RESULTS: Hypertension and obesity were found in 17% and 23% of students, respectively. Among hypertensive students, 88% (363/413) had isolated systolic hypertension. Hypertension was more prevalent in obese than nonobese students (33% vs 11%, P <.0001). Obese hypertensive students had higher resting heart rate than nonobese normotensive patients (85.9 vs 79.6 beats/min, P <.001). Among patients who underwent ABPM, isolated systolic hypertension was found in 51% (36/71) by clinic BP and in 62% (18/29) with confirmed hypertension by ABPM. Blood pressure variability during daytime and sleep periods was higher in obese than nonobese patients for systolic BP (P <.01) and diastolic BP (P <.05). CONCLUSIONS: The findings of increased heart rate and BP variability in obese children with isolated systolic hypertension suggest that sympathetic nervous system hyperactivity may contribute to its pathogenesis.

Ambulatory blood pressure and left ventricular mass index in hypertensive children.

To determine whether ambulatory blood pressure is more predictive of left ventricular hypertrophy than is casual blood pressure in hypertensive children, echocardiography and ambulatory blood pressure data from 37 untreated hypertensive children were analyzed. Left ventricular mass was calculated using the Devereux equation, left ventricular mass index was calculated as left ventricular mass (in grams)/height(2.7) (in meters), and left ventricular hypertrophy was defined as left ventricular mass index >51 g/m(2.7). Average blood pressure, blood pressure load, and blood pressure index (average blood pressure divided by pediatric ambulatory blood pressure 95th percentile) were calculated. Left ventricular mass index was strongly correlated with 24-hour systolic blood pressure index (r=0.43, P=0.008) and was also correlated with 24-hour systolic blood pressure (r=0.34, P=0.037), 24-hour systolic blood pressure load (r=0.38, P=0.020), wake systolic blood pressure load (r=0.37, P=0.025), sleep systolic blood pressure (r=0.33, P=0.048), and sleep systolic blood pressure load (r=0.38, P=0.021). Left ventricular mass index did not correlate with age, weight, clinic blood pressure, or ambulatory diastolic blood pressure. The overall prevalence of left ventricular hypertrophy was 27%. The prevalence of left ventricular hypertrophy was 47% (8 of 17) in patients with both systolic blood pressure load >50% and 24-hour systolic blood pressure index >1.0, compared with 10% (2 of 20) in patients without both criteria (P=0.015). These data suggest ambulatory blood pressure monitoring may be useful for the clinical assessment of hypertensive children by identifying those at high risk for the presence of end organ injury.