***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT The Systolic Hypertension in the Elderly Program ( SHEP ) demonstrated that treating isolated systolic hypertension in older patients decreased incidence of total stroke , but whether all types of stroke were reduced was not evaluated . OBJECTIVE To investigate antihypertensive drug treatment effects on incidence of stroke by type and subtype , timing of strokes , case-fatality rates , stroke residual effects , and relationship of attained systolic blood pressure to stroke incidence . DESIGN The SHEP study , a r and omized , double-blind , placebo-controlled trial began March 1 , 1985 , and had an average follow-up of 4.5 years . SETTING AND PARTICIPANTS A total of 4736 men and women aged 60 years or older with isolated systolic hypertension at 16 clinical centers in the United States . INTERVENTIONS Patients were r and omly assigned to receive treatment with 12.5 mg/d of chlorthalidone ( step 1 ) ; either 25 mg/d of atenolol or 0.05 mg/d of reserpine ( step 2 ) could be added ( n = 2365 ) ; or placebo ( n = 2371 ) . MAIN OUTCOME MEASURES Occurrence , type and subtype , and timing of first strokes and stroke fatalities ; and change in stroke incidence for participants ( whether in active treatment or placebo groups ) reaching study -specific systolic blood pressure goal ( decrease of at least 20 mm Hg from baseline to below 160 mm Hg ) compared with participants not reaching goal . RESULTS A total of 85 and 132 participants in the active treatment and placebo groups , respectively , had ischemic strokes ( adjusted relative risk [ RR ] , 0.63 ; 95 % confidence interval [ CI ] , 0.48 - 0.82 ) ; 9 and 19 had hemorrhagic strokes ( adjusted RR , 0.46 ; 95 % CI , 0.21 - 1.02 ) ; and 9 and 8 had strokes of unknown type ( adjusted RR , 1.05 ; 95 % CI , 0.40 - 2 . 73 ) , respectively . Four subtypes of ischemic stroke were observed in active treatment and placebo group participants , respectively , as follows : for lacunar , n = 23 and n = 43 ( adjusted RR , 0.53 ; 95 % CI , 0.32 - 0.88 ) ; for embolic , n = 9 and n = 16 ( adjusted RR , 0.56 ; 95 % CI , 0.25 - 1.27 ) ; for atherosclerotic , n = 13 and n = 13 ( adjusted RR , 0 . 99 ; 95 % CI , 0.46 - 2.15 ) ; and for unknown subtype , n = 40 and n = 60 ( adjusted RR , 0.64 ; 95 % CI , 0.43 - 0.96 ) . Treatment effect was observed within 1 year for hemorrhagic strokes but was not seen until the second year for ischemic strokes . Stroke incidence significantly decreased in participants attaining study -specific systolic blood pressure goals . CONCLUSIONS In this study , antihypertensive drug treatment reduced the incidence of both hemorrhagic and ischemic ( including lacunar ) strokes . Reduction in stroke incidence occurred when specific systolic blood pressure goals were attained . JAMA . 2000;284:465 - Background Since drug-related emergency department ( ED ) visits are common among older adults , the objectives of our study were to identify the frequency of drug-related problems ( DRPs ) among patients presenting to the ED with non-specific complaints ( NSC ) , such as generalized weakness and to evaluate responsible drug classes . Methods Delayed type cross-sectional diagnostic study with a prospect i ve 30 day follow-up in the ED of the University Hospital Basel , Switzerl and . From May 2007 until April 2009 , all non-trauma patients presenting to the ED with an Emergency Severity Index ( ESI ) of 2 or 3 were screened and included , if they presented with non-specific complaints . After having obtained complete 30-day follow-up , two outcome assessors review ed all available information , judged whether the initial presentation was a DRP and compared their judgment with the initial ED diagnosis . Acute morbidity ( “ serious condition ” ) was allocated to individual cases according to predefined criteria . Results The study population consisted of 633 patients with NSC . Median age was 81 years ( IQR 72/87 ) , and the mean Charlson comorbidity index was 2.5 ( IQR 1/4 ) .  DRPs were identified in 77 of the 633 cases ( 12.2 % ) . At the initial assessment , only 40 % of the DRPs were correctly identified . 64 of the 77 identified DRPs ( 83 % ) fulfilled the criteria “ serious condition ” . Polypharmacy and certain drug classes ( thiazides , antidepressants , benzodiazepines , anticonvulsants ) were associated with DRPs . Conclusion Elderly patients with non-specific complaints need to be screened systematic ally for drug-related problems . Trial Registration Clinical Trials.gov : Osteoporosis is responsible for about 1.3 million fractures in the United States each year [ 1 ] . Further , recent research has shown that the risk for most types of fracture in elderly women is related to low bone mass ; thus , the public health impact of osteoporosis may , in fact , be much greater [ 2 ] and is projected to increase over the next several decades [ 3 ] . Postmenopausal estrogen replacement is the current recommended therapy for the prevention of osteoporosis [ 4 ] . However , the use of estrogen is not widespread among elderly women [ 5 ] . Clearly , more options for the prevention of osteoporosis and fracture need to be developed and explored . One option is the use of thiazide diuretics . Thiazide diuretics are known to reduce urinary excretion of calcium [ 6 , 7 ] and may also decrease bone resorption [ 6 ] and bone turnover [ 8 ] . The use of thiazide diuretics has been associated with a reduced risk for fracture , with risk ratios ranging from 0.3 to 0.8 [ 9 - 18 ] . For example , in a casecontrol study that excluded patients taking other drugs thought to affect bone mass , Ray and colleagues [ 15 ] found a 50 % reduction in the risk for hip fracture among patients who had used thiazide diuretics  for 6 years . In addition , LaCroix and colleagues [ 16 ] reported a 30 % lower risk for hip fracture in current users compared with nonusers . The Framingham Study also showed a lower risk for hip fracture among users of pure thiazide drugs when compared with those using agents that combined thiazide diuretics with other antihypertensive drugs [ 17 ] . However , all of these studies have been observational , which allows the possibility that users of thiazide diuretics have a lower risk for hip fracture because of other confounding factors . In addition , the more recent data of Heidrich and colleagues [ 19 ] conflict with these results . These investigators found a crude odds ratio for thiazide use and hip fracture of 1.1 , which is not statistically significant . However , when they adjusted for the potentially confounding effects of nursing-home residence ; previous hospitalizations ; history of stroke , alcoholism or organic brain syndrome ; body weight ; leg paralysis ; and use of phenobarbital , corticosteroids , or other diuretics , a significantly increased risk for hip fracture was found among women who reported current use of thiazide diuretics  [ 19 ] . No study has prospect ively evaluated the relation between thiazide diuretics and other types of fracture . The mechanism by which thiazide diuretics might protect against hip fracture is not known . Thiazide diuretics may decrease fracture risk by preserving bone mass [ 10 , 11 , 20 - 23 ] . Cross-sectional studies have shown that users of thiazide diuretics have slightly higher cortical and trabecular bone mass than nonusers . Two r and omized clinical studies of the effect of thiazide diuretics on bone loss had conflicting results [ 24 , 25 ] . If thiazide diuretics reduce the risk for hip fracture by slowing bone loss , then these agents should also protect against other types of fracture that are associated with reduced bone mass [ 2 ] . On the other h and , thiazide diuretics could increase the risk for fractures by increasing the risk for falls [ 26 ] . Thiazide diuretics might do this by causing dizziness or postural hypotension [ 27 ] , although the association of diuretic use with falling is not consistent [ 28 ] . More than 90 % of hip fractures are related to falls [ 29 ] . No previous study has included a comprehensive analysis of the effects of thiazide diuretics on bone mass , the risk for falls , and the risk for all fractures in a single population . In our prospect i ve study of 9704 women who were 65 years or older ( the Study of Osteoporotic Fractures ) , we assessed thiazide diuretic use and bone mass at baseline and conducted follow-up examinations every 4 months for the occurrence of fractures and falls . Methods Study Sample From September 1986 through October 1988 , women who were at least 65 years old were recruited for the Study of Osteoporotic Fractures in four areas of the United States : Portl and , Oregon ; Minneapolis , Minnesota ; Baltimore County , Maryl and ; and the Monongahela Valley region near Pittsburgh , Pennsylvania . Age-eligible women were recruited through several sources : health maintenance organizations ; lists of residents that had been compiled for other epidemiologic studies ; jury- selection lists ; voter- registration lists ; and lists of driver 's license holders [ 30 ] . We excluded black women because of their lower incidence of fractures , women who were unable to walk without the assistance of another person , and women who had bilateral hip replacements . Measurement of Bone Mass Bone mineral content ( g/cm ) and density ( g/cm2 ) were measured using single-photon absorptiometry ( OsteoAnalyzer , Siemens-Osteon , Wahiawa , Hawaii ) . Details of these methods have been reported elsewhere [ 30 ] . We scanned three sites : the distal radius , the proximal radius , and the calcaneus . The distal radius is composed of about 60 % cortical bone and 40 % trabecular bone , the proximal radius is about 99 % cortical bone [ 31 ] , and the calcaneus is about 97 % trabecular bone [ 32 ] . The reproducibility of the bone mass measurements , expressed as coefficients of variation , ranged from 1.3 % to 2.0 % among individuals and from 0.4 % to 1.2 % among scanners [ 30 ] . Diuretic Use Information on diuretic use was obtained at the baseline clinic interview . Participants were asked to bring all current medications to the clinic for verification . In addition , pictures of tablets were presented to participants to assist them in the re collection of previously prescribed diuretics . Diuretics , including combination drugs , were classified as thiazide diuretics according to the American Medical Association drug evaluations [ 33 ] . Separate histories were obtained from participants for use of thiazide and nonthiazide diuretics . Chlorthalidone was classified as a thiazide diuretic because its effects on calcium excretion are similar to those of thiazide diuretics . Analyses in which chlorthalidone was not considered as a thiazide diuretic yielded similar results . Women were asked whether they had ever taken diuretics ; at what age they had started taking diuretics ; whether they were currently using diuretics and , if not , when they had stopped ; whether they took diuretics the entire time or stopped for a few years ; and the name of the medication they were currently using . Duration of diuretic use was calculated as the total number of years that they reported using diuretics . No information was collected on dose at the baseline visit , but dose-related data were recorded at the first annual telephone interview . Information on duration of thiazide diuretic use was missing in 15 women . These women were excluded from all analyses . Other Measurements Reported health status , type of menopause , alcohol consumption , and cigarette smoking were assessed using a question naire that was review ed with the participant by a trained interviewer . Women were considered to have had a surgical menopause if they reported having had a bilateral oophorectomy at the age at which they stopped menstruating . Regarding alcohol consumption , participants were asked how much they had consumed during the past 30 days and how many times they had consumed three or more drinks per day and five or more drinks per day during the past 30 days . The measure of alcohol consumption used in our study was drinks per week , which was adjusted for atypical drinking , particularly heavy drinking over the last 30 days .  Dietary calcium  was assessed by a food frequency question naire and an interview using st and ardized food models to estimate portion sizes [ 34 ] . In our study , total calcium intake included dietary and supplemental calcium . Women were also asked if they had ever taken the following medications : thyroid hormones , medicine for seizures , vitamin D or multivitamins containing vitamin D , TUMS , calcium supplements , antacids , prednisone , cortisone , other 
    Output:
    
Our results suggest that thiazides are efficacious in preventing cardiovascular events for this population group .
Low-dose regimens of thiazides may be safer than high-dose ( low quality of evidence ) , and a history of gout may increase the risk of adverse events ( low quality of evidence ) .
Conclusions The use of low dose treatment with thiazides for the management of hypertension in adults aged 65 and older seems justified , unless a history of gout is present .