Hypertension in Elderly Individuals from a City of Santa Catarina: A Population-Based Study

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1 370 Internacional Journal of Cardiovascular Sciences. 2015;28(5): ORIGINAL MANUSCRIPT Hypertension in Elderly Individuals from a City of Santa Catarina: A Population-Based Study Tuany Martins Nunes 1,2, Anneta Marcon Martins 1,2, André Luciano Manoel 1,2, Daisson José Trevisol 2,3, Fabiana Schuelter-Trevisol 2,3, Rodolfo Antônio Straioto Quirino Cavalcante 1, Felipe Zancan Espanhol 1, Tatiana Martins 1, Danúbia Felippe Grassi de Paula Machado 1, Roger Augusto Vieira e Silva 1 1 Universidade do Sul de Santa Catarina Faculdade de Medicina Curso de Graduação Tubarão, SC Brazil 2 Universidade do Sul de Santa Catarina Programa de Pós-graduação em Ciências da Saúde Tubarão, SC Brazil 3 Hospital Nossa Senhora da Conceição Centro de Pesquisas Clínicas Tubarão, SC Brazil Abstract Background: Aging is a global phenomenon. With population aging, there is an increase in the prevalence of non-transmissible chronic diseases, among which systemic arterial hypertension (SAH) is the most prevalent one. Objective: To estimate the prevalence of systemic arterial hypertension and associated factors in elderly individuals from the city of Tubarão, Santa Catarina, Brazil. Methods: Population-based cross-sectional study conducted with elderly individuals ( 60 years old) living in the city of Tubarão, Santa Catarina, Brazil, from September 2010 to May The individuals were interviewed and had their blood pressure (BP), weight and height checked. The variables analyzed were sex, age group, education level, ethnicity, alcoholism, smoking, obesity, physical activity and family history. Elderly individuals with blood pressure levels 140/90 mmhg or those using anti-hypertensive medication were considered hypertensive. Results: A total of 805 elderly individuals were interviewed, of which 699 (86.8%) were considered hypertensive. Of these, 56.2% had isolated systolic hypertension. All elderly individuals aged 80 had hypertension. The statistically significant variables were age, ethnicity, obesity and family history of hypertension. Conclusion: The prevalence of hypertension in elderly individuals was higher than that reported in research studies carried out in the city of Tubarão, Santa Catarina. The factors associated with hypertension were older age, nonwhite ethnicity, presence of obesity and positive family history. Keywords: Hypertension; Risk factors; Aged; Prevalence Introduction Aging is a global phenomenon. The proportion of individuals aged 60 is increasing more than any other age range 1. With population aging, there is an increase in the prevalence of non-transmissible chronic diseases, among which systemic arterial hypertension (SAH) is the most prevalent one 2,3. SAH is a multifactorial clinical condition characterized by blood pressure levels 140/90 mmhg. This disease has a high prevalence and low levels of control, Corresponding author: Tuany Martins Nunes Av. José Acácio Moreira, 787 Humaitá Tubarão, SC Brazil tuanymn@gmail.com DOI: / Manuscript received on September 11, 2015; approved on November 15, 2015; revised on November 20, 2015.

2 Int J Cardiovasc Sci. 2015;28(5): Nunes et al. 371 characterizing one of the main modifiable risk factors in relation to cardiovascular diseases 4. A study in Brazil found that the prevalence of SAH was up 55.0% in the elderly population in all geographic regions of the country 3. Another study reveals that among the risk factors for SAH, age has a direct and linear relationship, surpassing the 60.0% prevalence in people older than Besides age, other known risk factors are sex, physical inactivity, obesity, socioeconomic factors, smoking, alcoholism, among others 4,6,7. The aging process is dynamic and progressive and causes several changes in the human body 3. It involves the development of atherosclerosis in arteries and arterioles, decreasing their elasticity. The walls of vessels get stiff, which tends to increase blood pressure (BP), mainly systolic blood pressure 8,9. Consequently, with the installation of SAH, there is increased risk of comorbidities such as acute myocardial infarction, chronic renal failure and stroke 3. The objective of this study is to estimate the prevalence of SAH and associated factors in elderly individuals from the city of Tubarão, Santa Catarina, Brazil. Methods Members from the Family Health Strategies (FHS) program put together a database of 9,009 elderly people living in Tubarão. The sample size was calculated by specifying an error α of 0.05% and a 95% confidence interval (bilateral α of 0.025). An average prevalence of 60% of hypertensive patients, resulting in a minimum sample size of 356 individuals for a confidence level of 95% and power of study of 80% was used. In order to keep the power of the ABBREVIATIONS AND ACRONYMS BP blood pressure DBP diastolic blood pressure FHS Family Health Strategies HSEITU Health Study among Elderly Individuals of Tubarão SAH systemic arterial hypertension SBP systolic blood pressure study and extend the hypothesis test for the other variables of interest, in the event of losses or refusals, 20% was added to the calculated number of participants, totaling 428 individuals. The selection was carried out by systematic random sampling. From the list of elderly individuals registered by the Family Health Strategy teams, systematic sampling included all micro areas where the local community workers were active. The study included individuals aged 60 (completed in 2010), living in Tubarão, Santa Catarina, who agreed to participate in the study. Bedridden individuals, those unable to go to the healthcare center, with cognitive problems that prevented them from responding to the questions made or those unable to decide on their participation in the study were excluded from the research. Cross-sectional study with individuals from the Health Study among Elderly Individuals from Tubarão (HSEITU). HSEITU was carried out by the Department of Health from the city of Tubarão, Santa Catarina, and Universidade do Sul de Santa Catarina (UNISUL), from September 2010 to May 2011, in order to assess the conditions and health problems of the elderly population of the city, to create prevention and treatment policies to address the most prevalent health problems. The study was approved by the UNISUL Research Ethics Committee under no III and all elderly participants signed an Informed Consent Form. The variables analyzed were sex, age group, education level, ethnicity, alcoholism, smoking, obesity, physical activity and family history. An interview was conducted to collect the participants sociodemographic and health data. They also had their

3 372 Nunes et al. Int J Cardiovasc Sci. 2015;28(5): blood pressure (BP), weight and height checked. In cases where the pressure levels were compatible with diagnosis of SAH, the elderly individual was instructed to return to the clinic to be seen by a medical professional, complete the diagnosis and get advice. The interview, BP measurement and anthropometric measurements were taken by a trained health team, made up of health professionals and medical students, trained for carrying out the study protocol. For the interview, a structured standardized questionnaire was created by the proponents of the HSEITU study. To investigate alcohol abuse, the CAGE questionnaire was applied, in which two or more affirmative answers out of four indicate alcoholism. To define smoking, the criterion of the patient smoking or having smoked 100 or more cigarettes until the time of the interview was used. The participants were considered physically active if they had at least 30 minutes or more of physical activity, five or more times per week, resulting in a cutoff point 150 minutes of physical activity per week BP (mmhg) was measured in an automatic blood pressure monitor, brand OMRON, model HEM- 742INT (Dalian, China). The measurement was done 30 minutes after the participant had been at rest, sitting, without smoking or drinking coffee and with an empty bladder. Two measurements were made 20 minutes apart. The use of medically prescribed antihypertensive drugs of continuous use was also checked. To define the patient s SAH, the use of antihypertensive medications or high blood pressure levels was considered. The average of systolic blood pressure (SBP) and diastolic blood pressure (DBP) was used, considering SBP 140 mmhg and/or DBP 90 mmhg, according to the criteria of the VII Joint National Committee 14. Body weight (kg) and height (m) were measured using a portable digital scale brand Wiso model W71 (São Jose, SC, Brazil). To define obesity, body mass index calculated as the ratio between weight and height squared was used. Participants with BMI 30 kg/m 2 were considered obese. The data collected were included in the program EpiData software version 3.1 and statistically analyzed using the Statistical Package for the Social Sciences (SPSS) version 19. The quantitative variables were expressed as mean±standard deviation and the qualitative variables were expressed in absolute numbers and proportions. To check the association among the variables, the Chi-square test and the Student s t test were applied. The confidence interval was 95% and α error of 5%. Results Of the 1015 elderly individuals initially chosen, there were 98 refusals, 8 deaths, 11 were not found and 5 had moved, resulting in 893 elderly individuals. Of these, 88 did not show up on the days scheduled for data collection, resulting in 805 elderly individuals included in the study. Of this, 495 (61.5%) were women. The average age was 68.5±6.9. The average education was 4.1±3.4 years of study (Table 1). It was found that 393 (56.2%) elderly individuals presented changes in isolated SBP: 240 (61.0%) women and 153 (39.0%) men; and only 6 (0.9%) elderly individuals presented changes in isolated DBP: 4 (0.6%) women and 2 (0.3%) men. Regarding other blood pressure changes, such as systolic and diastolic hypertension, isolated diastolic hypertension and use of antihypertensive drugs, women accounted for 61.4% and men 38.6%.

4 Int J Cardiovasc Sci. 2015;28(5): Nunes et al. 373 Table 1 Sociodemographic and clinical variables of the individuals studied: normotensive and hypertensive patients Total n (%) Hypertensive individuals n (%) Normotensive individuals n (%) p Sample population 805 (100.0) 699 (86.8) 106 (13.2) Sex Male 310 (38.5) 271 (38.8) 39 (36.8) Female 495 (61.5) 428 (61.2) 67 (62.2) 0.69 Age group years 492 (61.1) 401 (57.4) 91 (85.8) years 245 (30.4) 230 (32.9) 15 (14.2) < years 68 (8.4) 68 (9.7) - Education 0 to 3 years 603 (75.1) 530 (76.0) 73 (68.99) 4 years 200 (24.9) 167 (24.0) 33 (31.1) 0.11 Ethnicity White 741 (92.0) 638 (91.3) 103 (97.2) Nonwhite 64 (8.0) 61 (8.7) 3 (2.8) 0.03 Alcoholism Yes 81 (25.6) 70 (25.8) 11 (23.9) No 236 (74.4) 201 (74.2) 35 (76.1) 0.78 Smoking Yes 326 (40.7) 280 (40.2) 46 (43.8) No 475 (59.3) 416 (59.8) 59 (56.2) 0.48 Physical activity Physically active 140 (17.4) 118 (16.9) 22 (20.8) Physically inactive 664 (82.6) 580 (83.1) 84 (79.2) 0.33 Obesity Yes 295 (37.0) 268 (30.8) 27 (25.5) No 502 (63.0) 423 (61.2) 79 (74.5) Family history of SAH Yes 697 (86.7) 509 (73.0) 67 (63.2) No 106 (13.3) 188 (27.0) 39 (36.8) Note: the total number of individuals with the variable alcoholism was 317, with 271 considered hypertensive and 46 considered normotensive. The sum total does not correspond to 805, because the individuals who did not drink did not respond to the CAGE questionnaire.

5 374 Nunes et al. Int J Cardiovasc Sci. 2015;28(5): Discussion A total of 805 elderly individuals were interviewed, of which 699 (86.8%) were hypertensive. This percentage is higher than that found in studies conducted in several centers of Brazil and the world, such as Campinas (state of São Paulo), Campo Grande (state of Mato Grosso do Sul), São Luiz (state of Maranhão), Athens (Greece) and Ottawa (Canada), which presented lower prevalence of hypertension in elderly individuals, ranging from 43.3% to 70.3% This may be related to eating habits and lifestyle or genetic predisposition, since obesity and a family history of SAH were associated with hypertensive elderly individuals. Besides this, in this study, the sample of elderly individuals is higher than the samples of the research studies mentioned, enhancing the reliability of results and reducing possible selection biases. In the age group of years, this study points out the existence of 230 (93.9%) hypertensive elderly individuals, a higher percentage than the one found in Campo Grande, state of Mato Grosso do Sul, which showed a prevalence of 62.3% (n=130) 16. In the age range 80 (n=68), there was a prevalence of SAH of 100%, confirming that the older the individual, the greater the risk of developing SAH. Another study conducted in Tubarão, Santa Catarina, in 2003, showed prevalence of SAH in elderly women (66.2%) and 67.8% in elderly men 20. In this study, 87.4% of men and 86.5% of women were hypertensive, demonstrating that, in less than a decade, there was a considerable increase in the number of elderly hypertensive patients in this city. There is a slightly higher prevalence of SAH in elderly men, both in the study published in 2003 and in this study, but with no statistical significance, consistent with a study published in Greece in A study conducted in Canada demonstrated higher prevalence of SAH in elderly women, also without statistical significance 19. Although some studies show low education and alcoholism as risk factors for the development of SAH 21,22, these variables were not associated with the outcome in this study. This may be due to the fact that most studies on SAH have been conducted with samples composed mainly of non-elderly adults. In this study, family history of SAH is positive in 86.7% of hypertensive individuals. This fact should call attention to the need to make public policies for the prevention of hypertension among the descendants of hypertensive elderly individuals so that educational measures such as diet and encouraging physical activity can reduce the incidence of SAH in these individuals. A study carried out in Presidente Prudente, state of São Paulo, found an association between family history of SAH and hypertension in 68.1% of the elderly individuals of the sample 19, as also found in this study. The results show that 638 (86.1%) individuals of white ethnicity and 61 (95.3%) of non-white ethnicity were hypertensive patients, with statistical significance (p=0.03). This finding indicates a higher prevalence of SAH in non-white individuals, which is consistent with that seen in other research studies 16, Despite the small number of non-white individuals in this study, which can be explained by the predominantly European colonization in southern Brazil, it can be inferred that the fact of not being white greatly increases the chances of being hypertensive. Physical activity was a protective factor for SAH in elderly women, as demonstrated in the literature in general. However, the samples of the research studies that have been found consist of adult populations, not specifically of elderly individuals 4, This highlights the gap regarding the population of hypertensive elderly individuals. Smoking and obesity were associated with increased SAH in elderly women. Other studies also show these associations, but these associations were found in adult populations rather than among elderly women 4, Of the study participants, 393 (56.2%) elderly individuals presented abnormalities in isolated SBP, a finding similar to that found in a study conducted in Boston, United States 29, with statistical significance: SAH percentage compared to other blood pressure changes especially in relation to isolated diastolic blood pressure, whose percentage in this study accounted for 0.85%, i.e., only six elderly individuals. This study had some limitations and its findings should be interpreted with caution. These limitations include the fact that the sample may not represent the population of local elderly people, as the FHS coverage rate is around 80-90%. It is clear that participants had a low education level and a predominance of females. Some participants could not visit the health centers, which resulted in some

6 Int J Cardiovasc Sci. 2015;28(5): Nunes et al. 375 losses (9.9%) that may have affected the results. In addition, the diagnosis of SAH need to be confirmed by checking BP three times during every other day, in addition to ambulatory blood pressure monitoring (ABPM). Conclusions The prevalence of hypertension in elderly individuals was higher than that reported in research studies carried out in the city of Tubarão, Santa Catarina. The factors associated with SAH were older age, non-white ethnicity, obesity and family history of SAH. The high prevalence of SAH in this population points to the need for improvements in health care, particularly related to prevention and treatment, since early diagnosis and control of blood pressure levels and related complications. The adoption of efficient nonpharmacological and therapeutic measures is an important resource for controlling and preventing SAH. Potential Conflicts of Interest This study has no relevant conflicts of interest. Sources of Funding This study had no external funding sources. Academic Association This manuscript is part of the Final Term Paper (TCC) in Medicine of Rodolfo Antônio Straioto Quirino Cavalcante from Universidade do Sul de Santa Catarina. References 1. Lima TAS, Menezes TMO. Investigando a produção do conhecimento sobre a pessoa idosa longeva. Rev Bras Enferm. 2011;64(4): Tavares DMS, Martins NPF, Dias FA, Diniz MA. Qualidade de vida de idosos com e sem hipertensão arterial. Rev Eletr Enf [Internet]. 2011;13(2): Disponível em: < doi.org/ /ree.v13i > 3. Mendes GS, Moraes CF, Gomes L. Prevalência de hipertensão arterial sistêmica em idosos no Brasil entre 2006 e Rev Bras Med Fam Comunidade. 2014;9(32): Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol. 2010;95(1 supl.1):1-51. Erratum in: Arq Bras Cardiol. 2010;95(4): Cesarino CB, Cipullo JP, Martin JFV, Ciorlia LA, Godoy MRP, Cordeiro JA, et al. Prevalência e fatores sociodemográficos em hipertensos de São José do Rio Preto. Arq Bras Cardiol. 2008;91(1): Tavares DMS, Marques ALN, Ferreira PCS, Martins NPF, Dias FA. Fatores associados à hipertensão arterial sistêmica e ao diabetes mellitus em idosos rurais. Cienc Cuid Saude. 2013;12(4): Santos JC, Moreira TMM. Fatores de risco e complicações em hipertensos/diabéticos de uma regional sanitária do nordeste brasileiro. Rev Esc Enferm USP. 2012;46(5): Gazoni FM, Braga ILS, Guimarães HP, Lopes RD. Hipertensão sistólica no idoso. Rev Bras Hipertens. 2009;16(1): Longo MAT, Martelli A, Zimmermann A. Hipertensão arterial sistêmica: aspectos clínicos e análise farmacológica no tratamento dos pacientes de um setor de psicogeriatria do Instituto Bairral de Psiquiatria, no município de Itapira, SP. Rev Bras Geriatr Gerontol [online]. 2011;14(2): Caballero Martínez L, Caballero Martínez F, Santodomingo Carrasco J. [Instruments for detecting alcoholism: remarks on the CAGE questionnaire]. Med Clin (Barc). 1988;91(13): Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of a new alcoholism screening instrument. Am J Psychiatry. 1974;131(10): Reichert J, Araújo AJ, Gonçalves CM, Godoy I, Chatkin JM, Sales MP, et al; Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes para cessação do tabagismo J Bras Pneumol. 2008;34(10): Erratum in: J Bras Pneumol. 2008;34(12): Sofi F, Capalbo A, Cesari F, Abbate R, Gensini GF. Physical activity during leisure time and primary prevention of coronary heart disease: an updated meta-analysis of cohort studies. Eur J Cardiovasc Prev Rehab. 2008;15(3): Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; the JNC 7 report. JAMA. 2003;289(19): Erratum in: JAMA. 2003;290(2): Zaitune MP, Barros MB, César CL, Carandina L, Goldbaum M. [Arterial hypertension in the elderly: prevalence, associated factors, and control practices in Campinas, Sao Paulo, Brazil]. Cad Saude Publica. 2006;22(2): Souza AR, Costa A, Nakamura D, Mocheti LN, Stevanato Filho PR, Ovando LA. Um estudo sobre hipertensão arterial sistêmica na cidade de Campo Grande, MS. Arq Bras Cardiol. 2007;88(4):441-6.

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