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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 55:M463-M468 (2000)
© 2000 The Gerontological Society of America

Hypertension in Elderly Persons

Its Prevalence and Associated Cardiovascular Risk Factors in Tainan City, Southern Taiwan

Feng-Hwa Lua, Shiung-Janp Tanga, Jin-Shang Wua, Yi-Ching Yanga and Chih-Jen Changa

a Department of Family Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan

Chih-Jen Chang, Department of Family Medicine, National Cheng Kung University Hospital, No. 138, Sheng-Li Road, Tainan 70428, Taiwan E-mail: fhlu{at}mail.ncku.edu.tw.

William B. Ershler, MD


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Hypertension was the eighth leading cause of death in Taiwan in 1996, and the prevalence of hypertension has increased recently. The purpose of the study was to assess the prevalence of hypertension and its associated cardiovascular risk factors in elderly persons in Tainan City, southern Taiwan.

Methods. The study was a cross-sectional, population-based study. We used the stratified cluster sampling method to enroll subjects aged 65 years and above, 1435 persons in total, into our study. Questionnaire interview, body weight, body height, and blood pressure measurement were completed for 876 participants (response rate of 70.2%) at each subject's home by home visit.

Results. Hypertension was defined according to the criteria of the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The crude prevalence of hypertension was 60.4% (men 59.1%, women 61.9%); previously diagnosed hypertension was 31.1% (men 29.4%, women 33.1%); and newly diagnosed hypertension was 29.3% (men 29.7%, women 28.8%). The hypertensive group had a higher body mass index (BMI) than the normotensive group. There were no lifestyle differences such as smoking, drinking, eating a vegetarian diet, reading health information, and undergoing a health examination in the past year between the hypertensive and normotensive groups. However, the hypertensive group had a higher prevalence of regular exercise than did the normal blood pressure group on univariate analysis. Only BMI and family history of hypertension had a significantly positive association with hypertension on multiple logistic regression analysis.

Conclusions. The crude prevalence of hypertension was 60.4% in elderly persons in Tainan City. Subjects who had family history of hypertension and higher BMI had a higher risk of hypertension, so they should be screened for high blood pressure regularly.

HYPERTENSION is the eighth leading cause of death in elderly persons in Taiwan in 1996 (1). It is also a major risk factor that is strongly, continuously, and independently related to stroke, congestive heart failure, coronary heart disease, renal disease, and peripheral vascular disease (2)(3)(4)(5)(6)(7)(8)(9). These risks have been shown for men as well as women (2). Because cerebrovascular accident, heart disease, renal disease, and hypertension were ranked as the second, fourth, seventh, and ninth leading causes of death in the total population in Taiwan in 1996 (10), hypertension recently became a public concern. Blood pressure and the prevalence of hypertension tend to rise with increasing age (3)(11)(12)(13)(14), and elderly people have a very high prevalence of hypertension, which markedly increases their morbidity and mortality (4)(5). Data from the Framingham Heart Study clearly showed increasing cardiovascular morbidity with increasing systolic or diastolic pressure in those aged 65 and over. This morbidity is at least double that seen in individuals aged 35 to 64 (5). The adverse effect of cardiovascular disease in elderly hypertensive subjects is two to three times higher compared with age/sex matched normotensive subjects (5).

The prevalence of hypertension in elderly persons is influenced by the spectra of definitions and accuracy of clinical methods of measurement (8)(13)(14) and has led to variable results. The rate was approximately 60% in non-Hispanic whites, 71% in non-Hispanic blacks, and 61% in Mexican Americans aged 60 years or older, as reported in the National Health and Nutrition Examination Survey III (NHANES III) (3), which defined hypertension as a systolic blood pressure (SBP) of >= 140 mmHg and/or a diastolic blood pressure (DBP) of >= 90 mmHg. The prevalence of hypertension in elderly persons aged 65 years or more was over 50% in a central European hypertension study (15) and was 44.6% in a Chinese study (16).

Factors associated with hypertension in the general population in epidemiological surveys included age, sex, race, socioeconomic status, psychosocial stress, genetic determinant, diet, smoking, alcohol consumption, physical activity, body weight, and awareness of hypertension (17)(18)(19)(20)(21)(22)(23)(24). We investigated whether those factors have the same influence in elderly persons. There have been many epidemiological studies of hypertension in the general population in Taiwan (25)(26)(27)(28)(29)(30), but only one set of data was available on the prevalence of hypertension in elderly persons, conducted during 1989–1991 (31). Because control of high blood pressure by modifying factors associated with the occurrence of hypertension is a major public health concern, the objective of this study was to investigate the prevalence of hypertension and its associated cardiovascular risk factors in elderly persons living in Tainan City, southern Taiwan.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
Study Population
Tainan is the oldest city in Taiwan and is located in the southern part of the country. It comprises seven administrative districts with more than 710,000 residents. The sampling scheme was a three-stage process that generated a stratified cluster sample of eligible subjects throughout the city. First, areas of the city were grouped into seven strata according to the administrative districts. One area (Li) was randomly selected from each stratum. Second, all those aged 65 years and older from each area were selected. In total, 1435 subjects were included in our study. Third, the selected subjects were informed about the survey by letter and telephone by the medical center and were asked for consent and to arrange the schedule of home visits.

Data Collection
A well-trained family physician and a research assistant performed the interviews from January through December 1995 via a home visit using a structured questionnaire. The questionnaire had three parts: (i) sociodemographic characteristics, including age, sex, marital status, education, occupation, and average income per month; (ii) health behaviors, including cigarette smoking, alcohol consumption, exercise, eating a vegetarian diet, reading health information, and undergoing a health examination within the past year; and (iii) detailed medical history of the subjects and their family. Body height (BH) was measured in centimeters using a ruler; body weight (BW) was measured in kilograms using a calibrated spring balance, with the subject wearing light clothing without shoes. Body mass index (BMI) was calculated for all individuals by using BW (kg) divided by BH squared (m2).

A mercury sphygmomanometer with standard cuff was used to measure the indirect auscultatory arterial blood pressure. Three consecutive blood pressure readings, separated by at least 5-minute intervals, were taken from the right arm, with subjects in a seated position. The SBP and DBP were determined by phases I and V Korotkoff's sound. Subjects were considered hypertensive if their average SBP >= 140 mmHg and/or DBP >= 90 mmHg, or if they used antihypertensive drugs and had blood pressure <140/90 mmHg (3). Newly diagnosed hypertension was defined when subjects had an average SBP >= 140 mmHg and/or DBP >= 90 mmHg but had never been diagnosed as having hypertension before this study.

"Current smoker" was defined as a subject who had smoked more than 100 cigarettes and was still smoking (32). "Ex-smoker" was defined as a subject who had previously smoked more than 100 cigarettes but had quit for more than one month. "Current drinker" was defined as a subject who consumed alcohol more than once a month (12), and a subject who previously had consumed alcohol but had not consumed any alcohol for one month was defined as an "ex-drinker." Exercise habit was recorded as "positive" if the individual exercised for over 30 minutes more than once in the past 2 weeks, otherwise the habit was recorded as "negative." "Full vegetarian" was defined as consuming vegetables all the time and "partial vegetarian" as eating vegetables at breakfast and/or on the 1st and 15th lunar days each month according to Chinese custom. Health information was defined as "positive" if the individual had read a book, magazine, or newspaper article that was related to health maintenance in the past year. Health examination was recorded as "positive" if the individual had received a general health examination in the past year. Hypertension is prevalent among first-degree relatives and related household members (33), so we also collected data about family history of hypertension.

Data Analyses and Statistical Methods
All continuous variables, including age, BH, BW, BMI, and blood pressure, were expressed as mean ± SD. The differences in sociodemographic data or health behaviors between responders and nonresponders, and between hypertensive and normotensive subjects, were compared using the chi-square test. The differences in age, BH, BW, and BMI between hypertensive and normotensive groups were compared using the two-tailed t test. All p values less than .05 were considered statistically significant. The data of those subjects with missing values were deleted when analyzing those data. Multiple logistic regression was used to assess the contribution to hypertension by different associated factors such as smoking, drinking, exercise, vegetarian habit, health examination, reading health information, family history of hypertension, BMI, age, and sex. All analyses were performed using the Statistical Package of Social Science for Windows software.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
A total of 188 of 1435 registered residents who were selected for the study were no longer living at their previous addresses. The response rate among the remaining 1247 subjects was 70.2% (876 of 1247). Reasons for nonrespondence were "impossible to contact during the three visits," 201 (54.2%); "live in other cities temporarily," 128 (34.5%); "refused to be interviewed," 25 (6.7%); and "health problems," 17 (4.6%). Table 1 shows there were no differences between responder and nonresponder groups in sex, education level, and occupation. The nonresponder group had a significantly higher average age and higher prevalence of widow/widower status than did the responder group.


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  		Table 1. Comparison of Sociodemographic Data Between Responders and Nonresponders

 
Table 2 shows the age- and sex-specific prevalence of hypertension. Under the criteria advocated by the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V), the crude prevalence rate was 60.4% (men 59.1%, women 61.9%), in which the prevalence was 31.1% (men 29.4%, women 33.1%) in previously diagnosed hypertension and 29.3% (men 29.7%, women 28.8%) in newly diagnosed hypertension. The peak prevalence was in the age group 75–79 years for both genders. The lowest prevalence was found in the age group >=80 years for both genders, especially in men. In total and in men, the prevalences of newly and previously diagnosed hypertension were nearly the same, but in women the prevalence of newly diagnosed hypertension was lower than that of previously diagnosed hypertension. Women had a higher prevalence than men after the age of 70.


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  		Table 2. Age- and Sex-Specific Prevalence of Hypertension in Elderly Persons in Tainan City, Southern Taiwan

 
Table 3 shows the average blood pressure levels for both sexes and various age groups. The SBP and DBP constantly decreased with increased age in men but not in women. The peak mean SBP was found in the age group 65–69 years in men but at 75–79 years in women. Men and women were similar in SBP and DBP for each age group, except in the age group 65–69 years, where men had significantly higher mean DBP than women.


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  		Table 3. Comparisons of Blood Pressure Levels (mmHg) by Sex in Different Age Groups in Elderly Persons in Tainan City, Southern Taiwan

 
There was no difference in sex, marital status, education, and income between subjects with normotensive and hypertensive groups. Table 4 shows the comparisons of clinical characteristics of normotensive, newly diagnosed and previously diagnosed hypertensive subjects. The total hypertensive, newly diagnosed and previously diagnosed hypertensive subjects had a higher mean BMI, SBP, and DBP than the normotensive subjects. There was no significant difference in mean age between normotensive and newly diagnosed, previously diagnosed, or total hypertensive subjects. The total hypertensive subjects exhibited a higher prevalence of exercise than normotensive subjects. There was no significant difference in the prevalence of lifestyle and health behaviors such as smoking, drinking, eating a vegetarian diet, reading health information, and undergoing health examination within the past year. The previously diagnosed hypertensive subjects had a lower prevalence of current smoking than the normotensive subjects, but there was no significant difference in smoking between the newly diagnosed hypertensive and normotensive subjects. The newly diagnosed hypertensive subjects had a higher prevalence of exercise than the normotensive subjects, but there was no significant difference between previously diagnosed hypertensive and normotensive subjects.


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  		Table 4. Comparisons of Clinical Characteristics of Normotensive, Newly Diagnosed, and Previously Diagnosed Hypertensive Elderly Subjects in Tainan City, Southern Taiwan

 
Table 5 shows odds ratios and 95% confidence intervals for independent variables with hypertension in the multiple logistic regression model. The independent variables were age, sex, education, marital status, income, smoking, drinking, exercise, vegetarian habit, reading health information, undergoing health examination, family history of hypertension, and BMI. According to the final best-fit model, the significant factors associated with hypertension were family history of hypertension and BMI, and exercise, age, sex, education, marital status, income, smoking, drinking, vegetarian habit, reading health information, and undergoing health examination were not significantly correlated with hypertension.


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  		Table 5. Multiple Logistic Regression Analysis of Hypertension in Elderly Persons in Tainan City, Southern Taiwan

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Our study is the first community-based epidemiological investigation of the prevalence of hypertension in elderly persons in Taiwan that measures blood pressure (BP) for all subjects in their home and uses the JNC V criteria as the definition of hypertension. The study avoids the weakness of overestimating BP by taking BP in hospitals or by doctors (34). The prevalence of hypertension in elderly persons in this study was 60.4% (men 59.1%, women 61.9%). Because nonresponders had significantly higher mean ages than responders, the prevalence of hypertension in elderly persons included in this study may be slightly higher than the real condition. In comparison with hypertension prevalence studies in Chinese in mainland China (44.6%) (16), the prevalence was higher. The prevalence was similar to that found by the Egyptian National Hypertension Project Study (56.6%–59.4%) (11), but slightly lower than that given in the NHANES III report (64.3%) (35). This high prevalence may be attributed to the Westernized life pattern (environmental factor) of the population in Taiwan, which is higher than that in mainland China. The prevalence of newly diagnosed hypertension (29.3%) was close to that of previously diagnosed hypertension (31.1%). This indicates that hypertension in elderly persons may be twice as prevalent in Tainan City as rates found in medical history surveys.

The prevalence of hypertension in the age group >=80 years for both genders, especially in men, was the lowest. This lowest prevalence may be related to the relatively smaller sample size in this age group. Because average systolic and diastolic blood pressures were significantly higher in Osler-positive subjects (36), the potential for higher prevalence of pseudohypertension in elderly persons in the age groups 65–69, 70–74, and 75–79 years who had higher systolic and diastolic blood pressures compared with those in the age group >=80 years should also be considered.

In our study, the means of SBP and DBP constantly decreased with age in men but not in women. The peak mean SBP was found in the age group 65–69 years in men but at 75–79 years in women. This result is different from that of the Starnberg study, or STEPHY, in which the SBP was higher in women than in men, and increased up to the age group 80–84 years both in men and women, although the DBP showed a constant decrease with age (15). The decrease in the means of SBP and DBP with age in men may be related to older individuals who had had a longer history of hypertension and had better compliance with antihypertensive treatment (37), but this finding needs to be further evaluated.

The association between hypertension and associated factors such as education level, economic status, and marital status is still questionable. In univariate analysis or multiple logistic regression analysis, these variables did not formulate into the best model. The same result was also true in the Six-Community Hypertension Intervention Project study (30). The familiar aggregation of hypertension found in this study is also consistent with previous studies (26)(38)(39), although much evidence suggests that blood pressure is influenced more by environmental factors than by heredity (17)(18)(19)(20)(21)(22)(23).

The association between obesity and hypertension has been amply demonstrated elsewhere (9)(40)(41)(42)(43)(44)(45). Similarly, in this study of a Chinese population in Tainan City, obesity, using BMI as an indicator, was positively related to hypertension after adjusting for the effects of age and sex. Some studies in elderly populations have also shown a correlation between body weight or BMI and SBP, particularly in men (46)(47)(48). The Honolulu Heart Program showed that BMI is significantly and independently associated with both SBP and DBP in elderly Japanese American men (48). Many cross-sectional and prospective observational studies have also identified a strong correlation between weight and blood pressure as well as a stepwise increase in blood pressure with progressively higher BMI (44)(45)(49)(50)(51)(52). In most studies, being overweight results in a two- to sixfold increase in the risk of developing hypertension. Although the effect of obesity on risk for hypertension has been shown to be more pronounced in individuals aged 20–45 years than among those aged 45–75 years (53), obesity-related hypertension in elderly persons cannot be regarded as benign because the relative risk for cardiovascular disease in elderly men increases from 1.8 to 2.9 times from the lowest to the highest tertile of BMI in hypertensives compared with normotensives (50). Weight reduction may be an important part of the prevention of hypertension, because weight loss can reduce blood pressure significantly by 15% and the effect of weight reduction exceeds that of all other nonpharmacological measures (41).

The relationship between hypertension and exercise has been mentioned in many studies (40)(54)(55)(56)(57). Most studies showed significantly lower hypertension prevalence in subjects participating in moderate or heavy exercise compared with sedentary subjects. In our study, exercisers had a significantly positive association with hypertension than did nonexercisers in univariate analysis ( p < .05), but exercise did not achieve statistical significance in the multiple logistic regression analysis, which took into account the effect of age, sex, smoking, drinking, vegetarian habit, reading health information, undergoing health examination, family history of hypertension, and BMI. This result was similar to the Jaipur study in western India in which more physical activity was associated with a greater prevalence of hypertension in both sexes (12). The possible reasons might be as follows: (i) once a patient was diagnosed as hypertensive, he or she might change his or her lifestyle or other relevant factors, and so it could be explained in our result that the hypertension group had a higher exercise habit than did the normal blood pressure group; and (ii) self-reported exercise assessments had well-known limitations. These limitations result from problems with the questionnaire itself or recall bias and can contribute to misclassification of exposure, which might diminish the strength of the association between physical activity and hypertension. Endurance exercise training by individuals who are at high risk for developing hypertension will reduce the rise in blood pressure that occurs with time, thus justifying its use as a nonpharmacological strategy to reduce the incidence of hypertension in susceptible individuals (54).

In conclusion, the prevalence of hypertension in elderly persons was 60.4% using JNC V criteria. The possible risk factors for hypertension were family history of hypertension and BMI. Because hypertension is a cardinal risk factor for cardiovascular morbidity and mortality, and because nearly half of the hypertensive elderly population do not know his/her hypertensive state, we should actively screen blood pressure in elderly persons to reduce their risk of having cardiovascular disease. Reduction of the modifiable factors such as BMI through public health programs may help the elderly to reduce the risk of hypertension.


   Acknowledgments
 
This study was supported by a grant from the Department of Health, Taiwan (DOH-84-TD-087). We thank the personnel of the Department of Family Medicine, National Cheng Kung University Hospital, Tainan, Taiwan for their full support and help.

Received January 22, 1999

Accepted December 5, 1999


   References
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 Abstract
 Methods
 Results
 Discussion
 References
 

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