The American journal of medicine
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Data from multiple sources confirm the greater risk of morbidity and mortality from cardiovascular disease that is seen in some minority segments of the population of the United States, when those segments are compared with the population as a whole. In most studies, blacks are shown to have the highest overall mortality rate from cardiovascular disease--higher than the rate for Hispanics, and substantially higher than the rate for whites and Asians. In some of these studies, blacks also have higher rates of both hypertension-related stroke and coronary artery disease. ⋯ Asians, by contrast, have significantly lower death rates from cardiovascular disease, irrespective of national origin, and they also have correspondingly lower mortality from stroke and other hypertension-related diseases. As in coronary artery disease, issues related to access to care may be implicated in the disproportionate morbidity and mortality rates noted in black and Hispanic patients, as well as among some lower-class segments of the non-Hispanic white population. Access to care may depend upon a number of factors, among them cultural isolation, public awareness, individual and group attitudes, perception of resource availability, actual resources, socioeconomic status, educational level, and peer behavior.
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The treatment of high blood pressure in black people is often complicated by a variety of factors. These include the tendency of black hypertensive patients to have three to five times the cardiovascular mortality of white hypertensive patients, black hypertensives' more frequent progression to end-organ damage and stroke, and socioeconomic conditions that impede access to proper health care. In addition, blacks have a unique hemodynamic profile, one that alters the efficacy of many antihypertensive drugs. ⋯ First, they present a better profile in terms of overall cost and compliance, thanks to their lower relative cost and once-a-day dosing. Second, when diuretics are combined with another antihypertensive therapy, such as an ACE inhibitor or a calcium-entry blocker, responsiveness may be further improved. This combination therapy may be especially important in black hypertensives, who exhibit a higher incidence of concurrent diseases such as left ventricular hypertrophy and congestive heart failure.
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Complaints of insomnia and disordered sleep are pervasive among the elderly, and reduced total sleep time and changes in sleep architecture are considered to be normal in the aging process. Additionally, numerous medical and psychiatric disorders that are highly prevalent in the geriatric population are known to affect sleep adversely. ⋯ Moreover, approximately 23 percent of Americans over age 85 reside in long-term care facilities, and institutionalization is an important risk factor for disordered sleep and for sedative hypnotic prescription. Consequently, the evaluation of any sedative hypnotic agent must include substantial assessment of efficacy, safety, and tolerance in geriatric patients.