Jose Ness

Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice

OBJECTIVE: To investigate the prevalence of coronary artery disease (CAD), ischemic stroke, and peripheral arterial disease (PAD), alone and in combination, in older persons.

Diabetes mellitus in older African-Americans, Hispanics, and whites in an academic hospital-based geriatrics practice.

BACKGROUND Diabetes mellitus is a risk factor for target-organ damage/clinical cardiovascular disease in older persons. DESIGN A retrospective analysis was performed of charts from all older persons (506 men and 1497 women, mean age 80 +/- 8 years) seen during the period from 1 January 1998 to October 1998 at an academic hospital-based geriatrics practice, to investigate the prevalence of diabetes mellitus, and the prevalence, in patients with diabetes, of target-organ damage/clinical cardiovascular disease, hypertension, hypertension or dyslipidaemia, obesity, the drugs used to treat diabetes, and poor glycaemic control. RESULTS Diabetes mellitus occurred in 127 of 1150 whites (11%), in 93 of 444 African-Americans (21%), in 111 of 381 Hispanics (29%), and in four of 28 Asians (14%) (P < 0.001 comparing Hispanics with whites and comparing African-Americans with whites; P < 0.01 comparing Hispanics with African-Americans). Of 335 patients with diabetes, 146 (44%) had coronary disease, 94 (28%) had stroke or transient cerebral ischaemic attack, 86 (26%) had peripheral arterial disease, 65 (19%) had heart failure, 107 (32%) had nephropathy, 71 (21%) had retinopathy, 47 (14%) had neuropathy, 284 (85%) had target-organ damage/clinical cardiovascular disease, 252 (75%) had hypertension, 300 (90%) had hypertension or dyslipidaemia, and 152 (45%) had obesity. The prevalence of stroke or transient cerebral ischaemic attack was greater in older African-Americans with diabetes mellitus than in older whites with diabetes mellitus (P < 0.02). The prevalence of diabetic nephropathy and of target-organ damage/clinical cardiovascular disease was greater in older African-Americans with diabetes mellitus than in older whites (P < 0.02) and Hispanics (P < 0.05) with diabetes mellitus. Increased concentrations of glycosylated haemoglobin (> 7%) occurred in 28 of 86 African-Americans (33%), in 69 of 104 Hispanics (66%), and in 23 of 118 whites (19%) (P < 0.001 comparing Hispanics with whites and comparing Hispanics with African-Americans; P < 0.05 comparing African-Americans with whites). CONCLUSIONS The prevalence of diabetes mellitus in 2003 older persons seen in an academic hospital-based geriatrics practice was 17% and was greater in Hispanics than in whites or African-Americans, and greater in African-Americans than in whites. The prevalence of target-organ damage/clinical cardiovascular disease was 85% in 335 older patients with diabetes. The prevalence of stroke or transient cerebral ischaemic attack was greater in older African-Americans with diabetes mellitus than in older whites with the disorder. The prevalence of diabetic nephropathy and of target-organ damage/clinical cardiovascular disease was greater in older African-Americans with diabetes mellitus than in older whites and Hispanics with diabetes mellitus. The prevalence of poor glycaemic control was greater in Hispanics than in whites or African-Americans and greater in African-Americans than in whites.

Prevalence of Prostate Specific Antigen Testing for Prostate Cancer in Elderly Men

PURPOSE We investigated the prevalence and outcome of PSA testing for prostate cancer screening or diagnosis in elderly men 75 years or older at our academic medical center. MATERIALS AND METHODS A cross-sectional study design was used to identify all men 75 years or older who underwent a PSA test through the family medicine or internal medicine service at our institution between January 1, 1998 and June 30, 2004. All patients with a suspected (PSA less than 0.1 ng/ml) or confirmed prior diagnosis of prostate cancer were excluded. The prevalence of PSA testing was then compared to that in younger age groups (45 to 54, 55 to 64 and 65 to 74 years). We then examined the frequency and nature of further evaluation and treatment performed in men following the PSA test. RESULTS The 8,787 male patients who were 75 years or older generated a total of 82,672 visits in the 5.5-year period. Of these patients 505 (5.7%) underwent at least 1 PSA test. The prevalence of PSA testing in the younger age groups was 10.3% (1,769 of 17,175) in patients 45 to 54 years old, 14.9% (2,052 of 13,772) in those 55 to 64 years old and 11.8% (1,258 of 10,661) in those 65 to 74 years old (chi-square test p <0.001). Of these patients 98 of 343 (28.6%) with PSA between 0.1 and 4 ng/ml were referred to a urologist at our institution and 3 underwent biopsy. None had a prostate cancer diagnosis. Of the 162 patients with PSA more than 4 ng/ml 84 (51.9%) were referred to a urologist. Only 10 of the 84 patients (11.9%) who were referred to a urologist underwent prostate biopsy. Six of the 10 men (60%) were diagnosed with prostate cancer, including 1 with a Gleason 6 tumor, 1 with a Gleason 7 tumor and 4 who were found to have tumors with a Gleason score of 8 or greater. All patients received androgen deprivation therapy, except 1 who received local external beam radiation therapy. An additional patient was diagnosed by biopsy of a vertebral lesion and he received hormone therapy. At a median followup of 51 months (range 28 to 72) 4 of 7 men (57%) were alive with disease. CONCLUSIONS PSA testing for prostate cancer screening and diagnosis appear to decrease with advancing age. A small but significant proportion of men who are 75 years or older continue to undergo PSA testing. Abnormal PSA results do not always result in further evaluation and therapy for prostate cancer in elderly men. The establishment of firm guideline recommendations regarding PSA testing and further evaluation for prostate cancer in elderly men, perhaps based on individualized geriatric assessment, may be helpful.

Prevalence and causes of persistent use of hormone replacement therapy among postmenopausal women: a follow-up study.

In a previous study analyzing data from September 2002 to February 2003, we showed that, despite the Womens Health Initiative trial results, many women still remained on hormone replacement therapy (HRT) in an internal medicine practice. However, it is not known whether such use has persisted over time. We performed a retrospective chart analysis of 1000 postmenopausal women seen at the same internal medicine practice from January 2004 to May 2004 to establish whether the prevalence of HRT use had declined, remained stable, or increased when compared with our previous data and to determine the reasons for continued HRT use. Among 1000 postmenopausal women, mean age 66±9 years, 116 (12%) remained on HRT (HRT users) in 2004. The prevalence of HRT users declined from 16% to 12% (P<0.01) over a period of 15 months. Among HRT users, the main reasons for continued use were severe menopausal symptoms in 39 (34%), patient preference in 17 (15%), osteoporosis or osteopenia in 14 (12%), failed attempt at discontinuation in 13 (11%), taper in progress in 12 (10%), gynecologist recommendation in 10 (9%), not documented in 8 (7%), and other reasons in 3 (3%). The use of HRT declined over time in an internal medicine clinic since the publication of the Womens Health Initiative study. However, 12% of the women still remained on HRT in 2004. The severity of menopausal symptoms, patient preference, and osteoporosis or osteopenia played a prominent role in the decision to remain on HRT.

Risk factors for coronary artery disease in old persons in an academic hospital-based geriatrics practice.

BackgroundRisk factors for coronary artery disease (CAD) in old men and women include age, cigarette smoking, hypertension, diabetes mellitus, dyslipidemia, and obesity. ObjectiveTo investigate the association of risk factors with prevalence of CAD. MethodsWe performed a retrospective analysis of charts for all old persons seen during the period from 1 January 1998 through 15 June 1999 at an academic hospital‐based geriatric practice to investigate associations of risk factors with prevalence of CAD among old persons. We studied 467 men, mean age 80 ± 8 years, and 1444 women, mean age 81 ± 8 years. ResultsCAD was present in 201 of 467 men (43%) and in 473 of 1444 women (33%;P  < 0.0001). Risk factors for CAD according to univariate analysis were age (P  < 0.0001 for women), cigarette smoking (P  < 0.0001 for men and women), hypertension (P  < 0.0001 for men and women), diabetes mellitus (P  < 0.0001 for men and women), obesity (P  < 0.0001 for men and women), and serum levels of total cholesterol (P  < 0.0001 for men and P  = 0.0001 for women), low‐density lipoprotein (LDL) cholesterol (P  < 0.0001 for men and P  = 0.001 for women), and high‐density lipoprotein (HDL) cholesterol (inverse association;P  = 0.0001 for men and women). Stepwise logistic regression analysis showed that significant independent risk factors for CAD were cigarette smoking (odds ratio 6.7 for men), hypertension (odds ratios 3.3 for men and 2.7 for women), and serum levels of HDL cholesterol (odds ratio 0.83 for men and women) and LDL cholesterol (odds ratios 1.10 for men and 1.09 for women). ConclusionsSignificant independent risk associations with prevalence of CAD among old persons were found for cigarette smoking by men, hypertension in men and women, and serum levels of HDL cholesterol (inverse association) in men and women, and of LDL cholesterol in men and women.

Underutilization of calcium and vitamin D by older adults in a large general internal medicine practice

The underutilization of calcium and vitamin D supplements in the prevention and treatment of osteoporosis is common among high-risk elders. Less is known about the prevalence and adequacy of calcium and vitamin D use by the general population of older adults. We performed a retrospective chart analysis of 617 women and 383 men over the age of 60 (mean age 73 ± 9 years) seen at an internal medicine practice to establish the prevalence and evaluate the adequacy of calcium and vitamin D supplementation. Adequate supplementation was defined according to the National Osteoporosis Foundation guidelines and the National Institutes of Health Consensus Development Panel on Osteoporosis. Osteoporosis or osteopenia was documented in 207 (33.6%) women and 21 (5.5%) men (P < 0.01). Of 383 men, 116 (30.3%) used calcium, 25 (6.5%) used adequate doses of calcium, 109 (28.5%) used vitamin D, and only 8 (2.1%) used adequate doses of vitamin D. Of 617 women, 415 (67.3%) used calcium, 199 (32.3%) used adequate doses of calcium, 347 (56.2%) used vitamin D, and 83 (21.7%) used adequate doses of vitamin D. When compared with women, men were less likely to be on calcium (OR 0.21, 95% CI 0.16-0.28), on adequate calcium replacement (OR0.15, 95% CI 0.11-0.23), on vitamin D (OR 0.32, 95% CI 0.25-0.42), and on adequate vitamin D replacement (OR 0.13, 95% CI 0.07-0.26). Calcium and vitamin D were greatly underutilized among older patients in an internal medicine clinic. Inadequate replacement doses were common, and men were particularly susceptible to undertreatment.