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Abstract

  1. Top of page
  2. Abstract
  3. Methodology
  4. Results
  5. Discussion
  6. Conclusions
  7. References

J Clin Hypertens (Greenwich).

A Harris Interactive survey of 1548 hypertensive persons aged 44 and older confirms the findings of previous studies that showed suboptimal rates of adherence to medication and lifestyle regimens to lower blood pressure, despite a high level of awareness of the health consequences of uncontrolled blood pressure. When the study population was analyzed by age group (baby boomers, ages 44 to 62 years, and seniors, ages ≥63 years), nonadherence was greater in the baby boomer cohort, which nevertheless had a higher level of concern than the seniors. Poor communication between patients and health care providers contributes to nonadherence to treatment regimens. Patients’ age plays an important role in their attitudes and behaviors regarding illness and treatment as well as their preferences as to the types of educational materials they would find helpful and the ways those materials can best be delivered. Because of the growing population of baby boomers further studies are warranted to evaluate attitudes, knowledge, and behaviors concerning the identification and treatment of hypertension.

Hypertension (HTN), defined as blood pressure (BP) consistently ≥140/90 mm Hg, is one of the most prevalent and serious risk factors for cardiovascular disease. Beginning with BP levels as low as 115/75 mm Hg, an increase in systolic and diastolic BP of 20/10 mm Hg is associated with a doubling of age-specific mortality rates from stroke, ischemic heart disease, and other vascular events.1 Nearly three-fourths of adults with chronic conditions such as coronary artery disease, heart failure, kidney disease, peripheral arterial disease, and diabetes mellitus have HTN.2

Data from the National Health and Nutrition Examination Survey (NHANES) 2005–2006 showed that one in three adults in the United States has HTN. This equates to 29% of the adult population.3 This percentage will likely continue to increase, primarily because of the aging of the population. The prevalence of HTN rises sharply with age,4,5 and 90% of persons with normal BP at age 55 will ultimately develop HTN.6 Other factors propelling the increase in prevalence include an increase in obesity,7 increased consumption of dietary sodium, a sedentary lifestyle, and suboptimal levels of health literacy.8 Although the government-sponsored project Healthy People 2010 has set as a goal to reduce the percentage of HTN to an age-standardized prevalence of 14%,9 recent reports have shown a rise in HTN prevalence, indicating that while we have made some progress in the area of HTN control, there is still a need for intensive efforts.8

It is well accepted that awareness, knowledge, and attitudes about HTN influence control rates. Health surveys are useful to assess patient attitudes and knowledge, adherence to guidelines, and quality of care. One survey showed that of adults ≥50 years of age who had their BP measured during the previous year, 46% did not know their BP, and, while 37% reported taking antihypertensive medication, only 27% stated that they had elevated BP.5

According to the 2000 United States census, more than 77 million individuals, were aged >50 years.10 The Preventive Cardiology Nurses Association (PCNA) hypothesized that this very large and growing population would be highly heterogeneous, and that awareness of issues related to HTN would vary considerably according to age. Because awareness of issues related to HTN guide education and treatment, a survey was conducted to determine whether in fact such awareness differed among persons older and younger than 62 years, and if so, in what ways.

The Hypertension 2008 online survey was conducted by Harris Interactive on behalf of PCNA to assess (1) the use of antihypertensive treatment regimens, including medication side effects; (2) patients’ attitudes about HTN and its management; (3) relationships between hypertensive patients and health care providers (HCPs); and (4) the role of support systems, including family and friends, in helping patients manage their HTN. This paper will report results in patients in the two age groups participating in the survey, baby boomers (BBs), who were 44 to 62 years of age at the time of the survey, and seniors (Ss), persons aged 63 years or older.

Methodology

  1. Top of page
  2. Abstract
  3. Methodology
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Sample

The Hypertension Survey 2008 was conducted online within the United States between June 18 and June 27, 2008. Harris PollSM, a multi-million-member panel of cooperative online respondents, conducted the survey. From this panel, qualified respondents were persons ages 44 or older who self-reported a diagnosis of HTN. As shown in the Figure, 5705 individuals with diagnosed HTN were e-mailed an invitation to participate in the survey. One thousand five hundred forty-eight qualified respondents completed the survey. Completion of the survey was considered as informed consent.

image

Figure Figure. Survey sample. Non-responders represent those who did not respond to the e-mail invitation. Non-qualified completes represent those who did not meet the screening criteria for entry into the study. Bounce backs represent e-mail invitations that were returned as undeliverable. Suspends represent those who began but did not complete the survey. Qualified/Over Quota represents those who qualified, but after the quota for the sample size had already been met. Qualified completes are those who met the screening criteria, and successfully completed the study.

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Data Collection Instrument

Survey participants were asked 124 close-ended questions. These included questions regarding demographics (12), medical history (10), medication use and adherence (6), relationships with HCPs (41), sources of information and social support (11), side effects of medications (15), and attitudes and information (29). The survey took about 17 minutes to complete. The survey results are reported at the aggregate level, not at the individual level. Thus the data and the results cannot be used to identify individual respondents. Results were weighted as needed for age, sex, race/ethnicity, education, region, household income, and the composition of US adults aged ≥40 years of age with HTN.

Statistical Analysis

Propensity score weighting was used to adjust for respondents’ propensity to be online. Descriptive data are presented as counts and proportions; chi square analysis was performed to determine statistical significance using Quantum software (SPSS Inc., Chicago, IL). Statistical significance was set at P<.05.

Results

  1. Top of page
  2. Abstract
  3. Methodology
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Demographics and Medical History

A total of 1548 online surveys were obtained. Demographic characteristics of the overall study population, BBs and Ss, are shown in Table I. Comparisons between the two subgroups showed that they were well matched for gender, location of residence, education level, and marital status. Since the study population was divided according to age, mean age differed for the subgroups (BBs = 53.7± 5.13 years, Ss = 72.0±6.05 years). More BBs than Ss reported a household income >$75,000 (30% vs 20%). In addition, compared with Ss, there were significantly fewer African Americans in the BB group (13% vs 8%) and significantly fewer retirees (20% vs 81%).

Table I.   Demographic Characteristics of Study Population and Age-Specific Subgroups of Baby Boomers (Aged 44–62 Years) and Seniors (Aged >62 Years)
 Overall Study PopulationBaby BoomersSeniors
N=1548n=672n=876
  1. aP<.05. aPercentages may not add up to 100% due to rounding, the acceptance of multiple responses, or the exclusion of “not sure” or “decline to answer” responses.

Mean age, SD (y)62±10.353.7±5.1372.0±6.05
Age categories (y)% OnlyN (%)N (%)
 44–4914216 (26)
 50–5416245 (29)
 55–5916244 (29)
 60–6413141 (17)62 (9)
 ≥6541 640 (91)
Men (%)50424 (50)346 (49)
Race/ethnicity
 White81662 (78)597 (85)
 Black/African American11112 (13)60 (8)
 Hispanic 549 (6)28 (4)
 Other –8 (1)8 (1)
 Declined to answer 114 (2)8 (1)
Location of residence
 Urban 205 (24)221 (32)
 Suburban 383 (45)302 (43)
 Rural 260 (31)178 (25)
Education
 High school or less46402 (47)312 (44)
 Some college25209 (25)171 (24)
 College or higher30235 (28)218 (31)
Marital status
 Married/living with partner63537 (63)445 (63)
 Divorced13137 (16)66 (9)
 Widowed1231 (4)159 (23)
 Separated 232 (4)3 (<1)
 Never married 9110 (13)29 (4)
Employment statusa
 Full-time37486 (57)84 (12)
 Part-time13130 (15)75 (11)
 Retired47166 (20)65 (81)
Household incomea
 <$35,00029238 (28)209 (30)
 $35–75,00029245 (29)208 (30)
 >$75,00025250 (30)142 (20)
 Declined to answer17114 (13)142 (20)
Hours per week spent on the Internet
  0  1 (<1)
  1–7 185 (22)168 (24)
  8–14 170 (20)152 (22)
 15–21 221 (26)196 (28)
 22–28 98 (12)74 (11)
 29–35 93 (11)65 (9)
 36–42 41 (5)20 (3)
 >43 38 (5)25 (4)

In addition to demographic characteristics, there were significant differences in medical comorbidities between the BBs and Ss (see Table II). Compared with Ss, BBs had significantly higher rates of obesity (34% vs 19%) and significantly lower rates of high cholesterol (53% vs 64%) and diagnosed heart disease (9% vs 22%). Table III shows family history of metabolic conditions and cardiovascular disease risk factors. Compared with Ss, BBs had significantly higher rates of a family history of diabetes (48% vs 29%) and obesity (36% vs 20%). Eighty-two percent of the BBs and 87% of the Ss also reported a family history of HTN.

Table II.   Self-Reported Vascular or Metabolic Conditions or Risk Factors Diagnosed by a Health Care Provider
 Baby Boomers, n (%)Seniors, n (%)
  1. aP=.05.

Hypertension/high blood pressure847 (100)701 (100)
High cholesterol450 (53)a452 (64)
Obesity291 (34)a131 (19)
Diabetes238 (28)181 (26)
Heart disease77 (9)a152 (22)
Kidney disease30 (4)26 (4)
Table III.   Reported Family History of Metabolic Conditions or Risk Factors
 Baby Boomers, n (%)Seniors, n (%)
  1. aP<.05.

Family history of hypertension740 (82)577 (87)
Diabetes405 (48)a205 (29)
Obesity307 (36)a144 (20)
Coronary heart disease358 (42)277 (9)

BP Goals

Seventy-one percent of BBs and 69% of Ss reported that they had never been given or were not sure that they had been given a BP goal. Of the 29% of BBs and 31% of Ss who said that they had been given a goal, two-thirds, respectively, stated that they had reached that goal.

Adherence to Therapy

Of respondents (99%) who were seeing an HCP about their HTN, 22% of BBs but only 5% of Ss said that they had ever stopped taking their medication on their own. Reasons for doing so included a prescription running out (BBs, 42%; Ss, 18%), forgetting (25% and 12%), and side effects (17% and 34%). Of those who had stopped taking medication on their own, 60% of BBs and 85% of Ss reported having admitted this to their HCPs; others did not tell, mainly because they were embarrassed.

Side Effects of Medication

Fifty-nine percent of BBs and 51% of Ss said that they had experienced side effects from their antihypertensive medications. The most common side effects were dizziness, fatigue, and sexual dysfunction for BBs and swollen ankles, fatigue, and sexual dysfunction for Ss. Most of these patients, 84% in both age groups, had reported their side effects to their HCPs. Of those who complained, only 27% of BBs and 29% of Ss reported that their HCP had changed their medication to reduce side effects. In both age groups, 16% of patients experiencing side effects did not tell their HCPs, mainly because they thought that their side effects either might not have been due to their BP medication or were not serious enough to voice complaints. Fewer than half the patients in each age group stated that they had been made aware of possible side effects of their medications at the time they were prescribed.

HTN Management and Control

While 66% of BBs and 73% of Ss believed that their BP was completely under control, 23% of BBs and 17% of Ss were unable to report their most recent BP measurement. Seventy-five percent of the BBs and 79% of the Ss were very confident or confident that they knew what to do to manage their high BP; the majority (91% of BBs and 97% of Ss) managed their HTN with antihypertensive medications and one or more lifestyle changes (Table IV). Most thought they were doing an excellent job of managing their BP (84% of BBs and 90% of Ss), although 28% of BBs and 21% of Ss admitted that they had been told that they needed to do better.

Table IV.   Strategies Used by Respondents to Manage Their High Blood Pressure
 Baby Boomers, n (%)Seniors, n (%)
  1. aP<.05.

Taking prescription medication774 (91)a680 (97)
Taking over-the-counter medication30 (3)33 (5)
Reducing salt intake550 (65)502 (72)
Limiting alcohol intake367 (43)338 (48)
Eating >5 servings of fruit and vegetables every day211 (25)192 (27)
Exercising moderately for 30 minutes, at least 3 times per week350 (41)a347 (50)
Maintaining low stress levels245 (29)a328 (47)
Maintaining a healthy weight232 (27)a294 (42)
No longer smoking204 (24)a286 (41)
Other36 (4)26 (4)

Office Visits With HCP

Subjects of discussion at patients’ initial visit with their HCP are listed in Table V. At these visits, 70% of BBs and 73% of Ss said that their HCP spoke to them about the importance of taking medication every day. Following their diagnosis of elevated BP, most respondents (87% of BBs and 90% of Ss) had follow-up visits with their HCP. In each group, >60% said that the consequences of uncontrolled BP were always discussed.

Table V.   Topics of Discussion During the Initial Visit With Health Care Provider
TopicBaby Boomers, n (%)Seniors, n (%)
Making lifestyle changes (diet, exercise, etc.)620 (75)476 (68)
Importance of taking medication every day583 (70)511 (73)
Effects of high blood pressure on health569 (69)457 (65)
Consequences of uncontrolled high blood pressure520 (63)436 (62)
Causes of high blood pressure457 (55)355 (51)
Importance of making follow-up visits406 (49)351 (50)
Side effects of medication365 (44)300 (43)
Other27 (3)28 (4)
None33 (4)16 (2)
Not sure30 (4)70 (10)

Of patients who had follow-up visits (89%) about their BP, 64% of BBs and 53% of Ss continued to have elevated BP. On those occasions, 52% and 41% in each group believed that their elevated BP was related to issues such as job stress, white coat syndrome, or anxiety about the visit.

Attitudes Toward Health and HTN

More than 60% of respondents in both groups described their health as excellent or good, despite the fact that both BBs and Ss reported that they had been told by an HCP that they had one or more vascular or metabolic diseases or risk factors (Table II). When asked how concerned they were about their HTN, 63% of BBs were very concerned or concerned compared to 54% of Ss. Ninety-one percent of BBs and 81% of Ss considered HTN a serious threat to their health. Among those respondents who did not consider their HTN a serious health threat, most said this was because they were able to manage their high BP.

Relationship With HCPs

Most respondents (83% of BBs and 91% of Ss) thought that the care that they received from their HCPs was excellent or good. In both age groups, 95% stated that their HCP listened to their concerns, and most believed that their HCP took the time to educate them about their high BP.

Other Sources of Information/Support

More than half of patients surveyed felt comfortable discussing their high BP with friends, their spouse or significant other, siblings, other family members, coworkers, and parents. Fifty-six percent of BBs and 57% of Ss reported that at least one friend or family member helped them manage their high BP: in most cases the helper was a spouse or significant other. The helper encouraged them to eat well and exercise, provided emotional support, reminded them to take their medication, accompanied them on medical visits, and sought information about HTN. However, 44% of BBs and 43% of Ss had no such support from friends or family members.

HTN Education

In both age groups, nearly half of respondents reported being at least somewhat interested to very interested in learning more about issues related to HTN. Thirty-four percent of BBs and 25% of Ss expressed interest in being able to access national medical guidelines written for patients. Other types of information that both BBs and Ss thought would be helpful were booklets describing lifestyle recommendations and treatment options, e-mail information, or online tools that would help them to track and manage their BP. In addition, 13% of BBs and 9% of Ss said that they would welcome tips on how to communicate better with their HCPs.

Discussion

  1. Top of page
  2. Abstract
  3. Methodology
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Our survey was unique in being able to compare two segments of older Americans. BBs today represent close to a quarter of the population of the United States.11 Because this huge, aging population will need increasing medical services, the attitudes and behaviors of BBs have important implications for health care delivery and costs.

In our study, with the exception of their younger age, BBs had more severe risk factors compared with Ss. BBs were more likely than Ss to report a family history of diabetes and obesity and also more likely to have been told by an HCP that they were obese. Nevertheless, fewer BBs than Ss were complying with lifestyle changes, including exercising, maintaining a healthy weight, reducing their sodium intake, eating healthy portions of fruits and vegetables, and quitting smoking. Thus, although BBs were more likely than Ss to consider their high BP a serious threat to their health and less likely to consider it well controlled, they were nevertheless more likely than Ss to be nonadherent to treatment advice. Further, not only were BBs more likely than Ss to have a high BP reading at a follow-up visit, they were also more likely to make an excuse for it. A common excuse was that they forgot to take their medication. Of those who considered that the management of their BP was only fair or poor, BBs were more likely than Ss to say that this was because they did not follow treatment advice. Compared with Ss, fewer BBs reported taking their medication as prescribed and preparing for follow-up visits to their HCPs.

What factors could explain the disparity between awareness and adherence in the BB population? First, a greater proportion of the BB population is working full-time. In addition, it is plausible that more BBs than Ss have children living at home, and, as the “sandwich” generation, they may also have parents living with them or requiring their assistance. With these competing demands for their attention, it would not be surprising if they forget to take their medication. Since only about one-third of the BBs who reported side effects from their medication had their medication changed, one might speculate that BBs decided that their HCPs were not responsive to their complaints and thus they would stop the medication on their own. More research is needed evaluating adherence to medications and side effects in BBs and Ss. HCPs need to work with BBs to help them find the best ways to live healthily, given the demands and constraints of their life situations.

Responsibility for suboptimal control rates does not lie with patients alone; clinical inertia in HCPs may result in a failure to increase inadequate doses of antihypertensive medications or to prescribe additional medications, per treatment guidelines.12 When patients’ efforts to lower their BP do not produce positive results, they are likely to produce instead apathy, discouragement, and nonadherence.

Our study points out that there is a need for educational efforts targeted toward specific age groups, as needs, lifestyles, and responses to therapy are likely to differ in important ways. For example, our survey found that BBs are more aware than Ss of their failure to manage their high BP optimally, but in order to do so, this age group may also require different kinds of educational tools. For example, BBs were more interested in having online access to national guidelines and Internet tools that provide support for lifestyle changes and medication adherence. In treating BBs and Ss, HCPs would do well to be more aware of the differences in attitudes, knowledge, and resources that characterize these two age groups.

Study Limitations

Results of this survey were based on respondents’ answers to a series of questions. Patients were not seen by HCPs and BPs were not taken. One question, “What excuses have you given for elevated BP on follow-up visits?” was open-ended; therefore some degree of subjectivity was introduced as verbatim responses were classified and coded. Because all respondents were comfortable participating in an online survey, populations were excluded and would conceivably have different preferences in terms of educational materials and mode of delivery. It should also be noted that although HTN is more prevalent and the sequellae more severe among African Americans,13,14 81% of participants in our study were white. Conceivably, a larger percentage of African-American respondents might have produced different results. Finally, because the sample is based on respondents selected from a group of persons who previously agreed to participate in Harris Interactive online, no estimates of theoretical sampling error could be calculated. Further, all sample surveys and polls, whether or not they use probability sampling, are subject to multiple sources of error which are most often not possible to quantify or estimate. All that can be calculated are different possible sampling errors with different probabilities for pure, unweighted, random samples with 100% response rates, but these are only theoretical because no published polls come close to this ideal.

Conclusions

  1. Top of page
  2. Abstract
  3. Methodology
  4. Results
  5. Discussion
  6. Conclusions
  7. References

HTN is both asymptomatic and endemic in older adults, and control of HTN remains a challenging and urgent public health issue. Although recent studies have reflected some improvement in the awareness and control of HTN in the United States,5 this is inadequate—BP is not well controlled in roughly two-thirds of hypertensive Americans.3 Our study showed that >90% of persons diagnosed with HTN are treated with some medication, and this is consistent with the results of previous surveys.15 Nevertheless, BP in treated individuals is still not controlled at target levels.15

The BB generation represents a large demographic that increasingly will need care for the diseases of older age, including HTN. BBs and Ss are likely to be treated similarly by HCPs, but their attitudes, knowledge, and behaviors concerning HTN are different, and their educational needs can best be met in different ways. Better communication between HCPs and patients can improve both understanding of the consequences of uncontrolled HTN and adherence to medical and lifestyle regimens. Further studies with larger and more varied populations are warranted.

Disclosure:  This paper was supported in part by an unrestricted grant to the Preventive Cardiovascular Nurses Association from Forest Pharmaceuticals. The authors acknowledge editorial support provided by Ruth Sussman, PhD.

References

  1. Top of page
  2. Abstract
  3. Methodology
  4. Results
  5. Discussion
  6. Conclusions
  7. References