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The Socio-Demography, Clinical Characteristics and the Prevalence of Cardiovascular Risk Factors Among a Group of Elderly Hypertensive Patients Followed Up at A Tertiary Care Hospital in Sri Lanka.
Hypertension is one of the most prevalent risk factors for myocardial infarction, strokes, congestive cardiac failure and chronic kidney disease (CKD)and its prevalence is significantly higher inthe elderly population.
To assess the demography, various presentations and the prevalence of risk factors among elderly hypertensive patients followed up in a tertiary care hospital in Sri Lanka.
This was a cross sectional descriptive study involving 250 patients whoseage was 60 years or above onantihypertensives for at least 6 months.
Approximately 65.2% of the study population was female. The mean age was 70.17.Dizziness and chest pain were the most prevalent symptoms.The mean age at first detection was 58.17 years.Mean SBP and DBP were 128.5mmHg and 81.14mmHg respectively. The prevalence of alcohol consumption and smoking among men were 70.1% and 72.4% respectively. Approximately 54.7% were either overweight or obese.Approximately 81.6% females and 41.4% males had a waist circumference ofmore than therisk level with p-value<0.05. Approximately 36% had diabetes mellitus and 27.6% of the patients had at least one parent and 36.8% had at least one sibling diagnosed with hypertension. Approximately 61.3% of the patients hadadequate levels of physical activity while 31.8% had IHD,11.5% had stroke and 3.8% had CKD.
Hypertension is one of the most prevalent and important modifiable cardiovascular risk factors for myocardial infarction, strokes, congestive cardiac failure, renal insufficiency and peripheral vascular disease 1, 2, 3. Hypertension in the elderly, i.e. systolic blood pressure (SBP) 140 or above and diastolic blood pressure (DBP) 90 or above in patients aged 60 years or more is considered to be a major factor that increases the mortality and morbidity in the elderly population 4, 5.
Until recently, elderly subjects were excluded from treatment studies, despite the fact that they are at high risk for complications or death from hypertension-related diseases.However, the benefits of antihypertensive drug therapy for older persons have been clearly established.Results from trials and meta-analyses have shown that antihypertensive drug treatment for older hypertensive persons confers highly significant and clinically relevant reductions in cardiovascular morbidity and mortality rates. Nevertheless, a considerable percentage of older persons with hypertension are not detected or are not adequately treated for hypertension.6
Hypertension in the elderly is important in many ways. The aging population has become a major concern for the whole world. The number of people aged 65 orabove, mainly in the developing countries of the worldis expected to increase from an estimated 524 million in 2010 to nearly 1.5 billion in 2050 7. Systolic blood pressure (SBP) tends to increase with age 8, 9. The pathophysiology behind this would be the arterial stiffness, intimal hyperplasia and non- compliance of the vasculature 9, 10, 11. Therefore, the prevalence of hypertension among the elderly population appears to be higher compared to the younger age groups. The prevalence of other chronic diseases and their risk factors, diabetes mellitus, dyslipidemia 12, 13,being overweight and obesity too is higher in the elderly 14. In addition, the elderly are more likely to have been exposed to certain life style risk factors for hypertension such as poor dietary habits, lack of physical activity, smoking and alcohol consumption simply due to their age 15.
Hypertension is considered a silent killer. This is due to the fact that most of the patients remain asymptomatic and areusually diagnosed at screenings, as an incidental finding or when presenting with a complication of this disease 5, 16. However, there are some warning symptoms which may suggest hypertension; headache, dizziness, nose bleed etc., but patients may easily ignore them. Complications of chronic uncontrolled hypertension vary from chronic conditions like cardiovascular disease or chronic kidney disease to acute hypertensive emergencies like aortic dissection or hypertensive encephalopathy 17, 18.
The situation in Sri Lanka is not too behindthe rest of the world. In the year 2000, every tenth person was aged and this proportion is projected to rise up to 22% by 2030 19. The prevalence of hypertension for men was 23.4% and 23.58% for women in 2014 and it is on average about a quarter of all Sri Lankans. It is projected to increase to 34.1% in 2020 making it a major burden on the country.20
The aim of this study is to describe the demography, major and minor presenting symptoms, prevalence of modifiable and non modifiable risk factors, associations between physical activity, lifestyle factors andthe control of hypertension and the prevalence of major complications of hypertension in a group of elderly hypertensive patients.
This was a cross sectional descriptive study conducted at the Hypertension Clinic and the Professorial Medical Wards (Wards 7 and 8) of the Teaching Hospital Peradeniya, Sri Lanka on the patients who are followed up for chronic hypertension.
Patients aged above 60 years,who had already been diagnosed as hypertensive and attending the weekly hypertension clinic or admitted to Medical Ward were randomly recruited.
The exclusion criteria were patients who had been diagnosed with hypertension within 6 months, amputees, plastered patients in whom blood pressure measurement and anthropometric measurements could not be carried out.Individuals with neurological disorders that may interfere with their understanding of the questions regarding the survey interview were also excluded.
Ethical clearance was obtained from the Ethical Review Committee of the Faculty of Medicine, University or Peradeniya, Sri Lanka.
All hypertensive patients aged 60 years and above who presented to the Teaching Hospital Peradeniya from August 2015 to December 2015.
Demographic data, details of risk factors including family history of hypertension, alcohol consumption, smoking and level of physical activity and dietary habits were collected using an interviewer administered questionnaire. Brief physical examination including blood pressure measurement was conducted by the investigators using standard techniques 21. Height was measured as the maximum distance fromthe heels to the uppermost position of the head, with the individual standing barefoot wearing light clothing and in full inspiration using Harpenden stadiometer (Chasmors Ltd., London, UK) to the nearest 0.1cm. Body weight was measured using a weighing scale to the nearest 0.1kg. Results of routine investigations were recorded.
Among the 250 study population,majority were females (65.2%).Mean age was 70.17 +/- 7.38 with minimum of 60 years and maximum of 94. Approximately 51.6% of the patients were under 70 years of age (Table 1). More than 90% of the patients were Sinhalese Buddhists followed by Moors. Majority of the females were widowed (Table 2).Table 1. Distribution of prevalence by gender and age groups
|AGE GROUPS - n (%)||Total|
|SEX||Female||42 (16.8 )||42 (16.8 )||37 (14.8 )||21 (8.4 )||21 (8.4 )||163 (65.2 )|
|Male||21 (8.4 )||24 (9.6)||17 (6.8 )||18 (7.2 )||7 (2.8 )||87 (34.8 )|
|Total||63 (25.2 )||66( 26.4 )||54 (21.6 )||39 (15.6 )||28 (11.2 )||250 (100 )|
|SEX n (%)||Total|
|ETHNICITY||Sinhala||152 (60.8)||77 (30.8)||229 (91.6)|
|Tamil||3 (1.2)||2 (0.8)||5 (2)|
|Moor||7 (2.8)||7 (2.8)||14 (5.6)|
|Other||1 (0.4)||1 (0.4)||2 (0.8)|
|RELIGION||Buddhist||152 (60.8)||77 (30.8)||229 (91.6)|
|Hindu||1 (0.4)||1 (0.4)||2 (0.8)|
|Islam||7 (2.8)||7 (2.8)||14 (5.6)|
|Christian||3 (1.2)||1 (0.4)||4 (1.6)|
|Other||0 (0)||1 (0.4)||1 (0.4)|
|MARITAL STATUS||Unmarried||7 (2.8)||1 (0.4)||8 (3.2)|
|Married||73 (29.2)||75 (30)||148 (59.2)|
|Widowed||80 (32)||11 (4.4)||91 (36.4)|
|Divorced / Separated||3 (1.2)||0 (0)||3 (1.2)|
|Total||163 (65.2)||87 (34.8)||250 (100)|
It is a common belief that hypertension does cause symptoms.When such symptoms are experienced most think it is due to elevated blood pressure.Majority of the patients complained ofor had dizziness as the foremost symptom and a majority of the patients had chest pain as a minor symptom (Table 3).Table 3. Prevalence of patients symptoms
|MAJOR SYMPTOMS||MINOR SYMPTOMS|
There was no significant difference in male and female groups in regard to the mean age at first detection of hypertension and current mean SBP (Table 4). Mean SBP and pulse pressure showed a peak in the 70 – 74 age group while the mean DBP continuously decreased with age (Table 5).Table 4. Mean Age at First Detection, Current Blood Pressure and Pulse Rate
|Sex||Mean Age at First Detection(SD)||Mean Systolic||Mean Diastolic||Mean Pulse Rate (SD)|
|BP (SD)||BP (SD)|
|Female||57.71 (9.9)||127.44 (36.0)||81.25 (10.9)||76.44 (11.1)|
|Male||59.31 (10.8)||130.53 (23.9)||80.93 (11.1)||75.87 (11.4)|
|Total||58.27 (10.2)||128.51 (32.3)||81.14 (10.9)||76.24 (11.1)|
|Age Groups||Mean SBP||Mean DBP||Pulse pressure|
The prevalence of risk factors among the study group including consumption of alcohol, smoking, family history and the prevalence of co-existing diabetes mellitus were analyzed. A majority of the patients neither consumed alcohol nor smoked and this was probably due to the fact that the majority of the group was female. However, from the 87 males who participated in the study, 61(70.1%) consumed alcohol and 63(72.4%) were smokers. Diabetes mellitus was prevalent in 36% of the patients. (Table 6).
Approximately 27.6% had at least one parent with hypertension while 36.8% had at least one sibling with hypertension (Table 7).Table 6. Prevalence of Cardiovascular Risk Factors
|p-value||1) 0.012, 2) 0.006, 3) 0.809|
|Family History of HTN||n||%|
|Parents with hypertension||Neither||139||-55.6|
|Siblings with hypertension||Non||128||-51.2|
Patients were categorized according to Body mass index (BMI) categories in accordance with the standard BMI cutoffs for Asians i.e., 18.5-underweight, 18.5-23 – normal, 23.1-27.5 – Overweight and >27.5 – obese 22. The majority of them (54.7%) were either overweight or obese. Mean BMI was 24.16kg/m2. Mean waist circumference was higher in females and 81.6% of females were above the risk level for South Asians. Their general activity levels are categorized according to the American Heart Association recommendations for adults i.e. 150min of moderate activity per week 23. The majority (61.3%) had adequate levels of physical activity (Table 8).Table 8. Life Style Factors and BMI
|N||Mean BMI 1||BMI Categories 2 - n (%)||Waist Circumference||Activity 4 (min/week)|
|(kg/m 2 )||UnderWeight||Normal||Over||Obese||Mean 3 (SD)||Normal a n (%)||Risk b||< 150||> 150|
The association between the prevalence of major cardiovascular diseases with gender and other risk factors among the study group was assessed. Approximately 31.8% of the patients had IHD, 11.5% had a history of stroke and 3.8% had CKD while 53.1% had none of thesemajor diseases (Table 9).Table 9. Association between Major Cardiovascular Diseases with Gender and Other Risk Factors
|MAJOR DISEASE||Total n||(%)|
|BMI Categories 4||Underweight||5||(2.4)||7||(3.4)||1||(0.5)||0||(0)||13||(6.3)|
|Activity 5||<150min/ wk||33||(14.7)||35||(15.6)||9||(4.0)||6||(2.7)||83||(37.1)|
According to the census of 2012; the population aged 60 years or more is 12.4% in Sri Lanka and it is expected toreach 24.8% in 204124. The prevalence of hypertension and its associated co-morbidities increase with age and it is one of the major factors contributing to the morbidity and mortality of theelderly.
This study was conducted at theTeaching Hospital Peradeniya, Sri Lanka, involving 250 patients who were aged 60 years or more with hypertension for at least six months. A majority of them were females, among themthe highest numbers of patients were widowed, and probably so because of their higher life expectancy 25. Previous studies done by Olack et al and Doulougou et al showed being widowed was independently associated with hypertension.26, 27From the patients whowere aged more than 80 years, 21 were female while only 7 were male. Regarding the demographic data, the majority were Sinhalese Buddhists followed by Moors which slightly differs from the general population in Sri Lanka 24. The mean age at first detection of hypertension was 58 years with no significant difference between males and females. The mean SBP and DBP were 128.5 and 81.1 respectively. Katulandaet al 20 reported that there is a significant difference in SBP in females and males considering the general population with higher value in females but we did not observe a significant difference in elderly hypertensive population who were on treatment. Japan which is a super aged society has reported a slight increase in mean SBP with ageing while a decrease of mean DBP causing wide pulse pressure 28. Our study population also showed a similarity with continuous decrement of mean DBP with age (p value-0.066).
Even though hypertension is considered an asymptomatic condition, several studies have been oriented to explorepatients’ beliefs about hypertension since the seventies.29 Some studies havenot found any relationship between reported symptoms and BP, arguing that hypertension has no specific symptoms that could be useful to the patient for anestimation of his/her blood pressure30 Other studies have found that a high percentage of hypertensive patients reported symptoms which they believed that were associated with high blood pressure and consequently used them to estimate their own blood pressure and to make decisions about treatment. This pattern of behavior can be considered as beliefs about false symptoms that could interfere with treatment.31 Beliefs about symptoms associated with hypertension can negatively affect adherence to treatment.Most patients interpret the perception of symptoms as a sign that their BP is high, which could pose the risk of changing their treatment protocol by themselves and vice versa.They interpret the absence of symptoms as a sign that their BP is controlled and this belief was associated with failures in adherence to treatment 32, 33. In our study,we inquired about the symptoms which patients have or had in the past and we especially asked for major symptoms which caused hospitalization, to seek medical attention or disturbances of day to day work and minor symptoms which patients may have ignored as they did not interfere with their regular activities. Most of the patients complained of or had dizziness as a major symptom followed by chest pain and headache. Chest pain was the most frequent minor symptom. Significant number of people did not have any symptoms.The original article published by Granados-Gamazet al shows a pattern between the groups in reporting the symptoms according to time since diagnosis, confirming that a longer history of hypertension is related to a higher probability of belief in symptoms. The percentage of symptomatic patients in the initial assessment is significantly less in the groups with a shorter time since diagnosis, and the bigger the difference in time since diagnosis, the bigger the differences between the groups in relation to the presence of symptoms29
In this study, we assessed the prevalence of common modifiable and non modifiable risk factors. Considering the cultural and ethnic situation in Sri Lanka, the number of female patients who smoke or consume alcohol was negligible (smoking 1 in 163 and alcohol consumption 2 in 163),but however from the male patients 70.1% were alcohol consumers and 72.4% were smokers. From the study population 35.6% of female and 36.8% of males were having diabetes mellitus. Most of the patients did not have a family history of hypertension. Several previous studies have shown a significant association of hypertension with these major risk factors 34, 35, 36, 37, 38, 39, 40.
According to the NICE guideline, the cut off values of BMI for Asians,22 majority of our study population were either overweight or obese. The mean BMI was 24.16 kg/m2 and the mean waist circumference was 90.22cm for females and 88.14cm for males with no significant difference in gender (p=0.193). However, 81.6% of females and 41.4% of males had waist circumference above the risk level for south Asians i.e. 80cm for female and 90cm for males (p-value<0.05)37, 38.Therefore, abdominal obesity is a major risk factor among elderly females. Previous study in Sri Lanka in 2014 reports the mean BMI as 23.1kg/m2 and mean waist circumference as 81.8cm in the general population (20). Therefore, the elderly hypertensive patients tend to have higher BMI and prevalence in central obesity. The majority of the patients had an adequate amount of physical activity as recommended by the American Heart Association for adults i.e. 150min per week 23.
With regard to major diseases contributed by hypertension,31.8% had ischemic heart disease, 11.5% had stroke and 3.8% had chronic kidney disease. Prevalence of these diseases showed a significant association with activity levels.A previous study done in Karnataka, India has shown a prevalence of 9.8% for ischemic heart disease and 5.7% for stroke in elderly hypertensive patients 41. Another study in Brazil has shown a significant association of major complications with themale sex 42.
There were some limitations in this study; the prevalence of major modifiable risk factors was reported as low due to the majority of the subjects being female.Further, selected subjects may not be a representative sample of the general population as this was a single station study.
Even though there have been previous studies in Sri Lanka to assess the prevalence of hypertension and risk factors inthe general population, this is the first study thatfocused on the elderly age group. Also,we could assess the prevalence of various presentations of hypertension which might be useful in early identification of patientsand to assess the control of the disease.
We have found that dizziness and chest pain were common symptoms among the elderly age group,and smoking and alcohol consumption among males.Abdominal obesity among females was another major risk factor. These areas need to be addressed to improve public awareness in order to detect early hypertension and prevent its devastating complications.
Ethical approval for this research work was obtained from the Ethical Review Committee, Faculty of Medicine, University of Peradeniya, Sri Lanka.All the data were collected from the participants after obtaining written consent.
UR conceived the research idea and guided it.UR and MB did the literature survey and drafted the paper. UR,MB,TJ and ST did data analysis. MB, NW and RB did data collection and entry. All authors made substantial contribution to design acquisition and interpretation of data and writing the manuscript and have given final approval of the version to be published. Also all authors agreed to beaccountable for all aspects of their work.
UR (MBBS, MD, MRCP, FRCP) is Senior Lecturer in Medicine and Consultant Physician. ST (MBBS, PhD) is Senior Lecturer in Community Medicine.TJ (MBBS, MD, MRCP, FRCP, FACP) is aProfessor in Medicine. MB (MBBS), NW (MBBS) and RB (MBBS) are Temporary Lecturers and Research Assistants.
We thank the study participants and staffs for their personal time and commitment to this study, and Mahes Salgado, the Head of the English Language Teaching Unit of the University of Peradeniya for editorial assistance.