|
Abstract
Background:
More than one half of the population of the elderly
care home, aged 65 or older has hypertension.
Aim:
to determine the prevalence of hypertension among
the residents of an elderly care home in north
Malaysia.
Methods:
This cross sectional study was carried out among
the residents of an elderly care home in north
Malaysia. Data was collected by trained research
assistants. Blood pressure was measured using
standardized methods using a manual sphygmomanometer.
Results:
The mean systolic blood pressure of the participants
was 140.89 (±13.22) and the mean diastolic
pressure 80.49 (±13.22). Differences in
the mean systolic pressure among the known hypertensives
and those who did not know of their condition
and the differences in the mean diastolic pressure
among those dependent on the activities of daily
living and those independent, were significant.
The prevalence of hypertension in this institution
was 50.9% (85). Six (3.6%) were known hypertensives
on medication and an additional 79 (47.3%) were
newly diagnosed. The known hypertensives were
more likely to have uncontrolled blood pressure
(OR 2.04) and residents with cognitive impairment
were more likely to have hypertension (OR 2.07).
Conclusion:
Screening for hypertension is a viable solution
to help detect hypertension early to reduce its
complications which include cognitive impairment.
Keywords:
Hypertension, elderly, elderly care home, Malaysia
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INTRODUCTION
The
numbers and the proportions of older adults are rising
rapidly in developed and developing countries. In 2006
almost 500 million people worldwide were 65 and older.
By 2030 it is projected to increase to 1 billion - one
in every eight of the earth's inhabitants. It is projected
that people aged 65 and over will soon outnumber children
under five in a very near future. This rise is due to
the reduced death rates among this group of people.(1,2)
The population of Malaysia is 25 million and is made
up of several ethnic groups, comprising mostly Malays
and other indigenous groups followed by Chinese and
Indians.(3) Due to improved health, longer life expectancy,
low mortality as well as declining fertility, it is
expected that by the year 2020, almost ten percent of
Malaysia's population will be aged 60 years and above.(4)
Institutional use by older adults
is usually associated with marital status, prior living
arrangements, health and economic recourses of the older
people and their children. Institutional residence is
also an option for older people who have difficulties
with activities of daily living or who require specialized
medical services.(1) In Malaysia, traditionally, it
is the role of the family to look after elderly people,
but because of the changes in cultural and social norms,
time, space and financial reasons there is an increasing
demand for nursing homes. At present institutional care
for poor, older persons in Malaysia is provided by the
federal government in old folks homes called 'Rumah
Seri Kenangan'.(5)
Chronic non communicable diseases
are now a major cause of death among older adults in
both developing and non developing countries. Death
rates due to cardiovascular diseases increase with age.
In developing countries cardiovascular diseases cause
twice as many deaths as HIV/AIDS, tuberculosis and malaria
combined.(1) Elevated blood pressure is an established
risk factor for cardiovascular diseases, stroke and
renal failure. It represents a pathophysiological manifestation
of altered cardiovascular physiology and structure morbidity,
ultimately manifesting as increased cardiovascular morbidity
and mortality. Prevalence of hypertension increases
with age. More than one half of the population aged
65 or older has hypertension.(6,7)
Hypertension is commonly
under diagnosed in elderly care homes because of the
shortage of health care professionals in these homes.
There are generally no symptoms in the early stages
of hypertension and hence diagnosis of this condition
is usually missed. The objective of the study was to
determine the prevalence of hypertension among the residents
of an elderly care home in north Malaysia.
METHODS
Setting:
The study was conducted in the largest government run
elderly care home in Malaysia. The criteria for admission
into this 200 bed institution includes: age over 60,
homeless or requiring care which the family cannot give,
and lack of funds to care for self.
Study Design: A cross sectional study design
was chosen to achieve the objective of the research.
Sampling: Participants were taken from among
the elderly (aged >60) residents of this institution.
Those who consented and who were able to communicate
effectively were eligible to participate.
Tools: The data was collected by trained research
assistants using a questionnaire especially designed
for this study. Besides the baseline demographic information,
blood pressure was measured using a manual sphygmomanometer
with the respondent sitting, having rested for 15 minutes.
Korotkoff Phase V (complete disappearance of sounds)
was considered to be the cut-off for diastolic pressure,
except where the sounds never disappeared (which can
happen in the elderly) then it was acceptable to use
Korotkoff Phase IV. Blood pressure was measured on 3
separate occasions and if the blood pressure was more
than 140 mmHg systolic or more than 90 mmHg diastolic
on all 3 occasions before, a positive diagnosis of hypertension
was made. This is in line with the criteria for diagnosis
of hypertension in all adults (including the elderly)
from the World Health Organization (WHO) and International
Society of Hypertension (ISH).(8)
Elderly Cognitive Assessment Questionnaire (ECAQ) and
Geriatric Depression Scale (GDS) were used to screen
the participants for cognitive impairment and depression.
In addition, Barthel index, which is a well established
and commonly used nursing tool, was used to assess the
functional independence in activities of daily living
(ADL) of the respondents. The respondents were categorized
as independent and dependent according to this index.
Body mass index (BMI) which is well recognized as an
easy and relatively accurate way to determine a person's
nutritional status was also measured.
Analysis: Analysis was done using SPSS version
13. 't', 'ANOVA' and Chi square test were used to analyse
the relationship between the variables. A p value of
<0.05 was considered statistically significant. Odds
ratio was used to estimate risk of hypertension.
Ethics: The research was conducted ethically.
The study had received the approval of the institutional
ethics committee and the approval of the management
of the institution before commencing. All respondents
were asked to give informed consent before starting
the interview.
The anonymity of the respondents was assured.
RESULTS
Out of the 200 residents
in the institution, 167 responded. Most were females,
in the age group 60-71, Malays, with no history of falls,
independent in the activities of daily living, not cognitively
impaired and not depressed. The majority of the participants
were malnourished.
| |
Systolic
(± SD)
|
't'
or ANOVA(F)/p
|
Diastolic
(± SD)
|
't'
or ANOVA(F)/p
|
| Sex |
|
-1.325 / 0.187
|
|
-1.551 / 0.123
|
| Female |
144.14 (± 25.87)
|
|
82.44 (± 13.87)
|
|
| Male |
138.76 (± 25.46)
|
|
79.21 (± 12.69)
|
|
| Age |
|
F 0.455 / 0.636
|
|
F 1.122 / 0.328
|
| 60-70 |
139.49 (± 23.42)
|
|
81.57 (± 13.41)
|
|
| 71-80 |
143.23 (± 28.44)
|
|
80.59 (± 13.56)
|
|
| >80 |
138.96 (± 25.05)
|
|
77.08 (± 11.59)
|
|
| Race |
|
F 0.623 / 0.538
|
|
F 1.424 / 0.244
|
| Malay |
141.72 (± 24.43)
|
|
82.10 (± 13.32)
|
|
| Indian |
137.00 (± 29.21)
|
|
77.83 (± 12.12)
|
|
| Chinese |
142.73 (± 24.73)
|
|
80.08 (± 13.78)
|
|
| Activities
of daily living |
|
0.996 / 0.320
|
|
2.027 / 0.044*
|
| Dependent |
143.96 (± 21.78)
|
|
83.67 (± 13.42)
|
|
| Independent |
139.61 (± 27.12)
|
|
79.16 (± 12.96)
|
|
| History
of falls |
|
1.223 / 0.223
|
|
1.534 / 0.136
|
| No |
139.92 (± 26.01)
|
|
79.88 (± 13.23)
|
|
| Yes |
146.96 (± 22.66)
|
|
84.30 (± 12.80)
|
|
| Cognitive
Impairment |
|
0.768 / 0.443
|
|
0.880 / 0.380
|
| Normal |
139.73 (± 26.55)
|
|
79.80 (± 12.46)
|
|
| Probable dementia |
142.90 (± 24.18)
|
|
81.67 (± 14.49)
|
|
| Depression |
|
0.737 / 0.462
|
|
0.995 / 0.321
|
| Normal |
143.52 (± 30.96)
|
|
81.88 (± 14.16)
|
|
| Depressed |
139.76 (± 23.18)
|
|
79.89 (± 12.81)
|
|
| BMI |
|
0.970 / 0.333
|
|
1.090 / 0.277
|
| Normal |
138.34 (± 26.94)
|
|
81.33 (± 14.27)
|
|
| Malnutrition |
142.35 (± 23.32)
|
|
79.02 (± 11.13)
|
|
| Known hypertension |
|
2.443 / 0.016 *
|
|
0.694 / 0.489
|
| No |
139.96 (± 25.53)
|
|
80.35 (± 13.39)
|
|
| Yes |
165.67 (± 16.35)
|
|
84.17 (± 6.79)
|
|
Table
1: Mean systolic and diastolic blood pressure profile
As shown in Table 1, the mean
systolic blood pressure of the participants was 140.89
(±13.22) and the mean diastolic pressure 80.49
(±13.22). Elevated systolic blood pressure was
noted among the females, those in the age group 71-80,
Malays and Chinese, those dependent in the activities
of daily living, those who have a history of falls,
the cognitively impaired, those not depressed, the malnourished
and among the known hypertensives. Differences in the
mean systolic pressure among the known hypertensives
and those who did not know of their condition and the
differences in the mean diastolic pressure among those
dependent in the activities of daily living and those
independent, were significant.
| |
Blood
pressure > 140 /90 (85)
f (%)
|
Normotension
(82)
f (%)
|
Total
(167)
f (%)
|
OR
(95%CI)
|
| Known hypertensive |
|
|
|
2.038 (1.74;2.39)
|
| Yes |
6 (100)
|
0 (0)
|
6 (100)
|
|
| No |
79 (49.1)
|
82 (50.8)
|
161 (100)
|
|
Table 2: Control of blood
pressure
| |
Hypertension
(85)
f (%)
|
Normal
(82)
f (%)
|
X2
/ p
|
OR
(95%CI)
|
| Sex |
|
|
1.163/0.281
|
|
| Male |
37 (56.1)
|
29 (43.9)
|
|
|
| Female |
48 (47.5)
|
53 (52.5)
|
|
|
| Age |
|
|
2.115/0.347
|
|
| 60-70 |
34 (45.3)
|
41 (54.7)
|
|
|
| 71-80 |
38 (57.6)
|
28 (42.4)
|
|
|
| >80 |
13 (50)
|
13 (50)
|
|
|
| Race |
|
|
2.149/0.341
|
|
| Malay |
44 (56.4)
|
34 (43.6)
|
|
|
| Indian |
17 (42.5)
|
23 (57.5)
|
|
|
| Chinese |
24 (49)
|
25 (51)
|
|
|
| History
of falls |
|
|
2.188/0.139
|
|
| Yes |
15 (65.2)
|
8 (34.8)
|
|
|
| No |
70 (48.6)
|
74 (51.4)
|
|
|
| Activities
of daily living |
|
|
0.130/0.719
|
|
| Dependent |
26 (53.1)
|
23 (46.9)
|
|
|
| Independant |
59 (50)
|
59 (50)
|
|
|
| Cognitive
impairment* |
|
|
4.995/0.025
|
2.07 (1.04;4.16)
|
| Yes |
38 (62.3)
|
23 (37.7)
|
|
|
| No |
47 (44.3)
|
59 (55.7)
|
|
|
| Depression |
|
|
0.945/0.624
|
|
| Normal |
51 (57.3)
|
38 (42.7)
|
|
|
| Depresion |
34 (43.6)
|
44 (58.4)
|
|
|
| BMI |
|
|
0.433/0.510
|
|
| Malnutrition |
56 (52.8)
|
50 (47.2)
|
|
|
| Normal |
29 (47.5)
|
32 (52.5)
|
|
|
*significant
Table 3: factors associated with hypertension
The prevalence of hypertension
in this institution was 50.9% (85). Six (3.6%) were
known hypertensives on medication and an additional
79 (47.3%) were newly diagnosed. As shown in Table 2
the known hypertensives were more likely to have uncontrolled
blood pressure (OR 2.04). As shown in Table 3 residents
with cognitive impairment were more likely to have hypertension
(OR 2.07).
DISCUSSION
Prevalence of hypertension in the Asia Pacific region
has been reported to range from five to 47% in men and
seven to 38% in women.(9) Based on the Malaysian National
Health and Morbidity survey III (NHMS III)(10) the national
prevalence of hypertension was 32.3%. The prevalence
of hypertension in this study was higher than the reported
prevalence in NHMS III. This is not surprising as the
prevalence of hypertension increases with increasing
age.(11) The high prevalence of hypertension in the
elderly may be attributed to age-related poor vascular
compliance of the large arteries, which subsequently
contributes to isolated systolic hypertension and widened
pulse pressure.(12) High prevalence of hypertension
among the elderly was also noted in studies conducted
abroad. In Singapore, the prevalence of hypertension
in the elderly was reported as 73.9% (13) which was
close to the figures reported in the United States (70.8%).(14)
In Europe similar patterns were found. In France, the
prevalence was reported as 62.0%,(15) in Portugal 78.9%
(16), England 80.5% (11) and Greece 89.0%.(17) In central
Malaysia the prevalence of hypertension among the elderly
living in a community was shown to be 25.6% (18) and
in northern Malaysia the prevalence was reported to
be 58.3%.(19) In institutions for the elderly the prevalence
of hypertension is generally higher. In the United States
of America (USA) the prevalence of hypertension has
been shown to range from 44-84%.(20-22) In central Malaysia
the prevalence of hypertension among the elderly living
in an old folks home has been reported to be 51.1% (23)
and in north Malaysia 62.6%(24) and 36%.(25) The difference
in the prevalence rates in different regions can be
explained by the difference in the economic development
and the affluence in different regions.
Awareness of hypertension ranges
from 30% (26) in the Far East to 46% in Europe (27)
to 78% in the USA.(28) In Malaysia the NHMS III (10)
found the awareness of hypertension to be low. In a
large study in Malaysia the awareness of hypertension
was found to be 35%.(29) In the present study only 7.1%
of the residents with hypertension were aware of their
condition. The awareness rate in this study is much
lower than other studies conducted in the private institutions
for the elderly in north Malaysia where the awareness
ranged from 64.9% to 81%.(24,25) This low awareness
can be explained by the fact that there are only two
medical support staff to care for the residents whereas
in the private institutions there were more care givers
and volunteer medical practitioners. Due to the shortage
of manpower to screen residents for hypertension and
because of the absence of overt symptoms in hypertension,(30)
the illness is not detected among the residents. Health
screening is an important aspect of health promotion
and disease prevention in people over 60 years. Screening
for hypertension can decrease morbidity and improve
quality of life in aging populations.(31) Because of
the higher risk, older people gain greater absolute
benefits from effective treatments. Early pharmacological
treatment of hypertension in the elderly can effectively
reduce morbidity and mortality from cardiovascular diseases
and stroke.(6)
The blood pressure of all six
participants who were aware of their condition was not
controlled. Control of blood pressure has been shown
to range from 1% in rural China (26) to 11% in Portugal
(27) and 44% in the USA.(28) Control of blood pressure
has also been shown to be a problem in Malaysia. NHMS
III (10) showed the control of blood pressure to be
26.3% whereas in another national study the control
of blood pressure was as low as 9%.(29) Blood pressure
control was shown to range from 34.4% to 48.1% in central
Malaysia (18,32) and 27.5% to 41.4% in north Malaysia.(19,33)
The control of blood pressure in private institutions
in north Malaysia ranged from 34 to 52.4%.(24,25) The
reason for the poor control of blood pressure could
be due to the poor compliance with treatment. A study
conducted in an outpatient clinic in Malaysia found
55.8% of patients on hypertension medication were not
compliant with treatment.34
Cognition declines with older age. Prevalence of dementia
which is characterised by a decline in memory, language
and other cognitive functions is high in the older population.
It is estimated that there is a new case of dementia
every seven seconds and the number of cases in the developing
world are forecast to increase by 100% between 2001
and 2040.(35) Prospective cohort studies have linked
the increased levels of blood pressure with increased
risk for dementia. High blood pressure increases the
risk for vascular dementia and Alzheimer's disease.(36,37,38)
Cognitive impairment poses a problem for compliance
with medication.
CONCLUSION
The prevalence of hypertension was high and blood
pressure control was poor in this study. Cognitive impairment
was shown to be linked to hypertension. Screening for
hypertension is a practical and economical solution
to detect hypertension early and subsequently reduce
its complications, which include cognitive impairment.
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