The “Nondipper” Elderly: A Clinical Entity or a Bias?

Objectives: To determine the prevalence of nondipper (ND) blood pressure profile in the elderly and to ascertain whether the ND pattern of ambulatory blood pressure in the elderly is an artifact or represents a specific clinical entity.
Design: Cross-sectional, observational study.
Setting: Cardiovascular diagnostic center, division of geriatrics, secondary care, institutional practice.
Participants: Sixty-five consecutive community-dwelling elderly hypertensive patients referred to the cardiovascular center.
Measurements: The patients underwent actigraphy and ambulatory blood pressure monitoring and completed a sleep assessment questionnaire. Patients were divided based on the night-time decrease in blood pressure (>10%: "dippers" (n=19); <10%: "NDs" (n=46)).
Results: Nondippers displayed poorer quality of sleep, as demonstrated objectively by actigraphic data; they obtained a higher mean score±standard deviation on the sleep questionnaire (4.6±2.9 vs 3.0±1.1, P =.030) and were taking more benzodiazepines (33.1% vs 10.7%, P =.035), indicating that their usual sleep quality was worse than that of dippers. Multivariate analysis showed a strong correlation between nondipper profile and quality of sleep and also with comorbidity, total number of drugs being taken, and pulse pressure.
Conclusion: Actigraphy demonstrates impaired sleep in the nondipper elderly. Nevertheless, the nondipping pattern seems independent of the discomfort of cuff-inflation during the night and occurs in association with higher comorbidity and polypharmacy; therefore, it cannot be considered a "bias," but is related to detrimental clinical conditions that should be studied in depth.     

“Are you better?” A qualitative study of the meaning of recovery

Purpose Research into the meaning of illness has often focused on an individual's transition into a state of being ill, for example the adoption of a sick role. The question “Are you better?” addresses the transition out of this state and is fundamental to the patient–clinician relationship, guiding decisions about treatment. However, the question assumes that all patients have the same meaning for “being better.” The purpose of this study was to explore the meaning of the concept of recovery (getting better) in a group of people with upper limb musculoskeletal disorders.

Methods

Qualitative (grounded theory) methods were used. Individual interviews were conducted with 24 workers with work‐related musculoskeletal disorders of the upper limb. The audiotaped interviews were transcribed and coded for content. Categories were linked, comparisons made, and a theory built about how people respond to the question “Are you better?”

Results

The perception of “being better” is highly contextualized in the experience of the individual. Being better is not only reflected in changes in the state of the disorder (resolution) but could be an adjustment of life to work around the disorder (readjustment) or an adaptation to living with the disorder (redefinition). The experience of the disorder can be influenced by factors such as the perceived legitimacy of the disorder, the comparators used to define health and illness, and coping styles, which in turn can influence being better.

Conclusion

Two patients could mean very different things when saying that they are better. Some may not actually have a change in disease state as measured by symptoms, impairments, or function.