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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57:M487-M491 (2002)
© 2002 The Gerontological Society of America

Age-Related Bias in the Management of Hypertension

A National Survey of Physicians' Opinions on Hypertension in Elderly Adults

Ihab Hajjara, Karin Millerb and Victor Hirtha

a Department of Internal Medicine, Division of Geriatrics, University of South Carolina School of Medicine/Palmetto Health Alliance, Columbia
b University of South Carolina School of Medicine, Columbia

Ihab Hajjar, Assistant Professor, Department of Internal Medicine, Division of Geriatrics, University of South Carolina School of Medicine/Palmetto Health Alliance, 9 Medical Park, Suite 230, Columbia, SC 29203 E-mail: ihab.hajjar{at}palmettohealth.org.


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. This study surveyed opinions and self-reported practices of physicians involved in the care of elderly individuals regarding geriatric hypertension management and included a national random sample (n = 1060) of health care professionals in the United States.

Methods. This is a cross-sectional self-conducted survey using a questionnaire developed to assess the opinions related to blood pressure (BP) and aging, BP selection, BP target, lifestyle modifications, and first-line drug choice. We also tested the impact of the patient's age on the respondents' answers. A national random sample (n = 1060) of health care professionals in the United States was selected.

Results. We received 412 (39%) questionnaires. Thirty-five percent considered that the increase in BP with age is a normal process of aging, and 25% considered treating hypertension in an 85-year-old patient to have more risks than benefits. Sixty-nine percent considered systolic blood pressure to be the most important pressure. Respondents were more likely to start antihypertensive therapy at a lower BP and target a lower BP in 65-year-old patients compared with 85-year-old patients (p < .001). Respondents were more likely to recommend lifestyle modifications in 65-year-old patients compared with 85-year-old patients (p < .001). Only 13–17% recommend higher potassium consumption. Diuretics (p = .032) and beta-blockers (p = .005), but not other antihypertensives, are less likely to be used as first-line drugs by respondents in the very old.

Conclusions. Health care professionals' understanding of BP changes with aging, BP selection and BP target levels, lifestyle modification counseling (especially concerning potassium consumption), and drug selection deviates in some aspects from the national recommendations especially in the very old. Improving these opinions could have a significant impact on the control rates of geriatric hypertension.

IT is estimated that about 60% of the U.S. population between the ages of 65 and 75 years and 70% of those 75 years or older have hypertension (1). More than 60% of these individuals have isolated systolic hypertension (2)(3). There is a large pool of evidence suggesting that lowering blood pressure (BP) in this group of the population, including the very old, will have a significant impact on the mortality and morbidity from hypertension in this country (3)(4)(5)(6)(7). Despite multiple clinical trials showing that lowering BP in the older patient is beneficial, epidemiological surveys have found a low rate of control in elderly adults (3)(8). Only a quarter of community-living, elderly, hypertensive patients are controlled (8)(9). In addition, recent analysis of the National Health and Nutrition Examination Survey III suggests that being older than 65 years and having isolated systolic hypertension are the highest attributable risks for both poor hypertension awareness and poor hypertension control in the United States (10). Identifying factors that contribute to these low rates will have important public health and economic implications (11)(12).

By the year 2020, 25% of the population will be older than 65 years, and the very old is the fastest growing segment of the U.S. population (13). Therefore, health care providers who manage elderly patients have a vital role in improving BP control in the United States. However, little is known about their opinions about managing hypertension in these patients.

We designed this study to survey opinions and self-reported practices of geriatric health care providers regarding the management of the elderly hypertensive patient. Our second objective was to identify factors, specifically the patient's age, which would impact these opinions and self-reported practices.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
This is a cross-sectional survey, using a mailed questionnaire, of opinions and self-reported practices of health care professionals (HCPs) who provide medical care to elderly individuals in the United States. The questionnaire was developed to assess multiple aspects of HCPs' opinions and self-reported practices regarding the management of the elderly hypertensive patient. These include opinions about pathophysiology and self-reported practice habits regarding nonpharmacological therapy and pharmacological therapy. Opinions about pathophysiology were assessed using questions regarding BP and aging and regarding which BP (systolic blood pressure [SBP] vs diastolic blood pressure [DBP]) is considered more important in the management of elderly hypertensive patients. Self-reported practices about nonpharmacological therapy were assessed using questions regarding frequency and type of lifestyle modification (LSM) the participants use in their practices. We used a scale of 4: never, rarely, sometimes, and always. Self-reported practices about pharmacological therapy were assessed by asking about the threshold of SBP and DBP at which the participants would start pharmacological therapy after adequate LSM, the target SBP and DBP in the same situation, and the choices for first-line drugs. To assess the impact of the patient's age on the opinions and self-reported practices of HCPs, we used two generic case scenarios in which the only difference was the patient's age (65 years old vs 85 years old). To further assess the impact of the patient's age, we inquired about the participants' opinions about the risk-benefit ratio of treating hypertension in the very old (older than 85 years). In addition, we asked the participants to provide information regarding their age, gender, number of years since graduation from medical school, primary specialty (internal medicine [IM] vs family medicine [FM]), geriatric fellowship training, and practice setting (academic vs nonacademic, rural vs urban). The state and zip code of the participant's practice were also included in the questionnaire. The developed questionnaire was piloted on HCPs in the local institution to assess feasibility, reliability, and estimated time needed to complete the questionnaire.

The American Geriatrics Society (AGS) mailing list was used to identify HCPs in the United States who take care of elderly patients. The AGS is the organization of professionals who specialize in health care of older adults. AGS membership is comprised primarily of geriatric health care professionals (14). The list included the names, addresses, institutions, and degrees of 4024 members. A random sample of 1060 was selected with a balanced geographic distribution across the United States. The survey was mailed with a cover letter stating the purpose of the study.

Data from the completed questionnaires were entered into a database, and accuracy was tested using cross-referencing to the returned questionnaires in a random subgroup of entries. To study the impact of the patient's age on HCPs opinions and self-reported practices, chi-square test for proportion was used to compare the responses to the two case scenarios. In addition, the impact of the HCP's age, gender, years since graduation, and practice setting was also investigated using the chi-square test, the t test, and one-way analysis of variance. For the geographic comparison of HCP opinions, the country was divided into four regions (West [W], Midwest [MW], Southeast [SE], and Northeast [NE]) using the Bureau of Census Statistical Groupings (15). Minitab software was used to perform the analysis.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
We received 412 surveys (39% response rate). Of those, 10 were from individuals who were not involved in patient care, and 19 were from respondents who no longer treat patients. A total of 383 completed questionnaires were used in this analysis. The mean age of the respondents was 48.3 ± 0.5 years and 35% were women. The mean number of years since graduating from medical school was 21.4 ± 0.5 years. The primary specialty of the respondents was IM in 65% and FM in 35%. Forty-nine percent were fellowship-trained geriatricians, 46% practiced in an academic setting, and 10% were practicing in a rural setting. The geographic distribution of the respondents was 16% W, 26% MW, 26% NE, and 32% SE.

Of all the respondents, 134 (35%) considered the increase of BP with aging a normal part of the aging process. There was no difference in the respondents' opinions based on their age, gender, years since graduation, fellowship training, or their practice setting or region.

Thirteen percent considered DBP as the most important pressure in treatment of the elderly hypertensive patient, and 69% considered SBP as the most important. Eighteen percent considered both to be important. HCPs with FM as their primary specialty (p = .011) and HCPs practicing in the W (p = .016) or in academic settings (p = .042) were more likely to select SBP (Table 1 ).


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  		Table 1. Differences in Blood Pressure Selection Versus HCP Characteristics

 
Of all respondents, 96 (25%) considered treating patients older than 85 years with mild to moderate hypertension as having more risks than benefits. There was no difference in the respondents' opinions based on their age, gender, years since graduation, and their practice setting or region.

When asked about the frequency of checking orthostatic BP in elderly hypertensive patients, 6.8% responded that they never or rarely do, 53% responded they sometimes do, and 40% said they always do.

HCPs were more likely to recommend lifestyle modification in a 65-year-old patient with hypertension than in an 85-year-old (77% always recommend and 22% sometimes recommend in a 65-year-old vs 38% always recommend and 51% rarely recommend, p < .001). Eleven percent would never or rarely recommend lifestyle modification to 85-year-old patients. With advancing patient age, HCPs were less likely to recommend all types of lifestyle modification (Table 2 ). Only 13–17% would recommend an increase in dietary potassium to an elderly patient with hypertension.


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  		Table 2. Impact of Patient's Age on Frequency of Recommending Various Types of Lifestyle Modifications in Hypertensive Patients

 
HCPs were more likely to start antihypertensives at a lower BP and aim toward a lower target BP in the 65-year-old patient (Table 3 ). In a 65-year-old hypertensive patient, 65.6% would start pharmacological therapy if SBP is greater than 140 mm Hg after adequate lifestyle modification, and 33% of respondents would only start antihypertensive if SBP is greater than 160 mm Hg. In an 85-year-old patient, 42% would start pharmacological therapy if SBP is greater than 140 mm Hg after adequate lifestyle modification, and 50% would start pharmacological therapy if SBP is greater than 160 mm Hg (Table 3 ). In a 65-year-old patient, the majority (90%) would target a SBP less than 140, whereas in an 85-year-old, 65% would target a SBP less than 140 mm Hg (Table 3 ).


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  		Table 3. Impact of Patient's Age on Threshold of Starting Pharmacological Therapy and Target Blood Pressure After Starting Treatment

 
In both case scenarios, HCPs were more likely to select diuretics as first-line therapy. This was followed by angiotensin converting enzyme inhibitors, beta-blockers, calcium channel blockers, angiotensin receptor blockers, and alpha-blockers, respectively (Table 4 ). Diuretics and beta-blockers were less likely to be used with advancing patient age (Table 4 ).


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  		Table 4. Impact of Patient's Age on First-Line Drug Selection in Elderly Hypertensive Patients

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
This is one of the few U.S. surveys of geriatric HCPs' opinions about management of hypertension in both the old and the very old hypertensive patient. We have identified various opinions and self-reported practices that could impact care of the elderly hypertensive patient. A significant proportion (35%) of our respondents thought that increased blood pressure is a normal aspect of aging. This is in contradiction to the vast amount of evidence that an increase in blood pressure is not normal aging (3)(16)(17). This could lead to underdiagnosis and undertreatment of hypertension in the elderly individual.

Recent evidence suggests that SBP is a more important predictor in elderly adults (18)(19)(20). Our survey shows that the majority of HCPs selected SBP or both BPs as important in managing an elderly hypertensive patient. This is higher than prior surveys performed in the United States and other countries (21)(22)(23). For example, a survey in England of general practitioners found that 34% would not treat isolated systolic hypertension (23). More recently, intensifying treatment occurred in 24% of the visits when DBP was greater than 90 mm Hg versus only 4% when SBP was greater than 140 mm Hg in the United States (24). In our survey, there was no difference in respondents' opinions based on the HCP's age, which has been identified in prior studies as a factor that may impact a physician's opinion and practices (25)(26).

Lifestyle modification is an important aspect of hypertension management in the elderly hypertensive patient, and counseling has a positive impact on the patient's healthy habits (27)(28)(29)(30). In addition, prior studies have found that elderly hypertensive patients with healthier lifestyles can decrease the number of antihypertensives needed to control their BP (31). We found that with increasing patient age, HCPs were less likely to recommend lifestyle modification. Improving health habits could then not only improve control rates but also decrease the problem of polypharmacy in the elderly patient.

We found that HCPs rarely recommend an increase in dietary potassium (13%–17%) in the hypertensive elderly patient. Multiple studies have shown that increasing potassium in the diet can lower blood pressure (32)(33), and increasing dietary potassium is a part of the lifestyle modifications recommended by the Joint National Commission sixth report (27). A similar finding has been reported previously where only 3% of family practitioners and 5% of internal medicine specialists in Canada recommended increasing dietary potassium for their hypertensive patients (34). This stresses the need for programs that would improve HCP education about the role of potassium in managing elderly hypertensive patients. Similarly, the self-reported rate of counseling about limiting alcohol consumption is low and should be a part of the management of hypertension (27).

Multiple studies have shown that lowering SBP to below 140 mm Hg in the elderly patient is associated with a lower risk of complications (18)(19)(20). A significant proportion of our respondents (34%) would not start pharmacological therapy if SBP were greater than 140 mm Hg. This was even higher (58%) if the patient was older than 85 years. Moreover, we found that the patient's age plays an important role in deciding the target BP, with HCPs using higher target blood pressures in older patients. This has been reported previously in other countries (22)(23)(35)(36), and it may explain, in part, the low rate of control in the elderly population in the United States. This poses an urgent need to improve HCPs' opinions about target BP in the elderly hypertensive patient.

Diuretics were the drugs most commonly reported as first-line therapy. This is in agreement with the evidence that they lower morbidity and mortality in the hypertensive elderly patient (4)(5)(6)(7). Angiotensin converting enzyme inhibitors (ACE-I) were the second most common drug selected. Recent evidence suggests that ACE-I have a positive outcome in the elderly hypertensive patient (7). Our finding is in agreement with some but not all prior surveys showing that ACE-I use is on the rise in the United States and elsewhere (26)(35)(37)(38). We have also found that, in the very old patient, HCPs were less likely to use diuretics and beta-blockers, but there was no difference in the use of the other classes. The reasons for these differences are unknown.

The advantage of this survey is that it investigates opinions of providers who are at the forefront of health care for the elderly hypertensive patient. These opinions play an important role in shaping providers' practices. Also, it gives a comprehensive snapshot of these opinions and sheds more light on possible explanations for the low rate of control in this population. Moreover, it is one of the larger surveys to be conducted in this arena.

The limitation of this survey is that it measures opinions and self-reported habits. It does not measure actual practices. Furthermore, it represents a random sample of HCPs who are listed on the AGS mailing list. It does not include professionals involved in the care of elderly hypertensive patients who are not members of or affiliated with this organization.

Geriatric HCPs play an important role in the health care of the elderly population. We have identified multiple areas in their opinions and self-reported practices that deviate in some aspects from the national recommendations. Improving the HCPs' understanding of BP changes with aging, BP selection, and BP threshold and target levels, encouraging lifestyle modifications (especially increasing dietary potassium and limiting alcohol intake), and drug selection could potentially have a significant impact on the control rates of geriatric hypertension. More focused programs on the management of hypertension in the very old could further improve these rates.

Received February 15, 2002

Accepted February 21, 2002


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

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