Rationale for Study
Research stuthes initiated by professional nurses in the clinical setting are rare! Solicitation from nurses in a school of nursing to analyze the data and report the findings is even rarer! However, the following study was conducted by professional nurses with assistance from a non -professional volunteer staff in a county health department located in a large metropolitan city in an attempt to evaluate factors that may influence blood pressure readings of ambulatory elderly seen in health screening clinics.
The faculty members were approached regarding data analysis after the data had been collected; therefore, opportunity to assist with the study design was not possible. Consequently, limitations inherent in the study (e.g., no reliability check of blood pressure procedure; self-reporting on selected parameters such as drug knowledge, weight, etc; and non-completion of all items on the questionnaire which resulted in different numbers of responses regarding individual variables) became evident in the analysis of data.
Where an interest in nursing research is found, however, it should be encouraged. With this philosophic stance, the study is reported. Although not pure in design, it does reflect findings of interest to community health nurses who interact with elderly clients.
Hypertension is said to be a common problem of the elderly ambulatory population in the United States. The literature provides a wide variation in norms of blood pressure (BP) levels established for the diagnosis of hypertension.1"3 In the elderly population, cardiovascular disease contributes to increasing morbidity that may be related to underlying aging processes, pathology, and/or environmental factors. It has been shown that blood pressure is modifiable by such factors as change in life style, decrease in salt intake, control of obesity, and lessening of stress.5,6 While this generally may be the case, a question remains about the association of these factors to blood pressure readings of the ambulatory elderly.
Lack of knowledge of the normal range of blood pressure readings in the ambulatory elderly may lead to unnecessary treatment with drugs of high potency to relieve symptoms attributed to high blood pressure. Failure to recognize postural hypertension in the elderly may lead toan incorrect diagnosis of cerebrovascular insufficiency2 and create additional problems. Thus, further study of the normal range of blood pressure in the ambulatory elderly is essential.
Emphasis today is not only on longevity but also on quality of life of the elderly living in the community. The quality of life is affected by the aging individual's state of well-being and ability to meet his or her needs independently. Hypertension, a major health problem, interferes with achievement of goals related to the desired quality of life. Health professionals, especially nurses, are in key positions from a health education and health counseling point of view7 to help the elderly understand factors that may influence and control their health status and quality of life.
To relate effectively to the aging in the community, the nurse must be knowledgeable about the life style and disruptive elements in the lives of these aging persons that affects their cardiovascular system, specifically their blood pressure. Accuracy of the blood pressure reading is crucial. Since information collected in the assessment process is used to measure the health status of elderly individuals and becomes the basis upon which the health care regimen is established, comprehensive, accurate data are essential. The physiological and psychological parameters, as well as the blood pressure readings themselves, are important areas of assessment. Environmental factors, both internal and external, have a great deal of influence on quality of life.
Statement of Problem and Purpose
The problem under study was: What relationship exists between blood pressure readings and selected parameters - age, sex, weight, smoking habits, activity level, medication intake, exercise level, and self-knowledge of hypertension - in an elderly ambulatory population? The purpose of this investigation was to determine this relationship.
Review Of Literature
Sheehy ' notes that "systolic blood pressure rises with age, the rate of rise differing from individual to individual and that the blood pressure level remains essentially unchanged with age." Sheehy cites the study by Anderson and Cowan,1 which describes the arterial blood pressure of 374 men and 254 women in relation to age and sex. In this study, "mean systolic blood pressure levels for men increased from 153 mm Hg in those 60 to 64 years old to 168 mm Hg in those 80 to 89 years old and from 164 to 183 mm Hg for women in the same age category."
On the other hand, Caird and Judge2 indicate that there is an increase in both the systolic and diastolic blood pressure in the well elderly. Upper limits of blood pressure in old age, cited by Caird and Judge, are higher than those cited by the American Heart Association.8
Numerous stuthes have been carried out that demonstrate varying norms established for diagnostic purposes in the elderly population. Master and Lasser,9 after studying 5,727 healthy non-institutionalized individuals, concluded that the upper limits of normal for arterial blood pressure are 160/100 mm Hg for aged men and 180/90 mm for aged women.
Ward,10 indicated that a study initiated in 1972 by the National High Blood Pressure Education Program (NHBPEP) provided data that shows within the past five years the "number of hypertensive persons whose blood pressure is poorly controlled or not controlled is increasing."
Finally, Caird and Judge2 observed that blood pressure levels in elderly people who are well, with no evidence of damage to their hearts or vascular systems from high blood pressure, reflect a range of 200 to 210 mm Hg systolic and 100 to 115 mm Hg diastolic. Sex differences in blood pressure levels are reflected - the normal limit of 210 systolic, 115 diastolic in women over 80 years of age; 195 systolic, 105 diastolic in men over 80 years of age. Blood pressure readings below these normal levels, according to Caird and Judge, are considered acceptable and should not be considered indicative of high blood pressure; older persons should not have symptoms attributed to the blood pressure or be treated for high blood pressure when they ate well and have no evidence of pathology.*
The literature review indicates a wide variation in what have been used as "norms" for blood pressure readings in the elderly. Further research is indicated to identify norms of blood pressure readings for the ambulatory elderly to be used in community-based screening clinics and in the development of respective treatment protocols.
The null hypothesis to be tested is: There is no relationship between the blood pressure readings and selected parameters - age, sex, weight, smoking, activity level, medications, exercise, and selfknowledge of hypertension - in an urban ambulatory, elderly population.
Blood Pressure Reading: A single unit of measurement depicting the diastolic and systolic arterial blood pressure in an individual.
Urban Ambulatory Elderly Population: A non-institutionalized ambulatory elderly population above 60 years of age that uses health screening services provided at a Senior Citizen Center.
Selected Parameters: Risk factors, including physiological factors, which may influence the health status of an elderly individual and be reflected in blood pressure readings, specifically, age, sex, weight, smoking, activity level, medications, exercise and self-knowledge of hypertension.
Out of 3,000 elderly ambulatory citizens in an urban midwestern community who frequented the blood pressure screening clinic sponsored by the nursing services division of a local health department, a convenience sample of 526 male and female subjects participated voluntarily in a descriptive study of blood pressure readings and selected parameters.
Two screening sites were selected to be used on two separate days for the study. A workshop on taking blood pressure readings was conducted for volunteers who were female adults from the two neighborhoods where the clinics were to be held. Presentations were given by professional nurses on the physiological mechanisms of blood pressure; the norms to be used for establishing readings indicative of elevated blood pressure according to age ( 140/90 was used for persons under 50 years of age and 165/95 for those over 50 years of age as promulgated by the American Heart Association); and the procedure for taking the blood pressure reading.
A short questionnaire (Figure 1) was devised to collect demographic data and information on the selected parameters. These indicators were self-reported by clients, an acceptable methodology for research.
Institutional consent for the study was obtained from the director of the midwestern Health Department. Clients participating indicated their consent by completing the questionnaire.
Data were examined by categorization of the variables. X2 test was used to determine the significant relationships among the variables selected for the study.
In Table 1, the systolic blood pressure readings on 526 subjects shows the smallest value obtained was 102 mm Hg; the largest value was 240 mm Hg; with a mean of 154.31 mm Hg and a standard deviation of 20.94 mm Hg. In the diastolic blood pressure readings on 525 subjects, the smallest value obtained was 62.00 mm Hg; the largest value was 130.00 mm Hg, with a mean of 93.06 mm Hg and a standard deviation of 10.23 mm Hg.
Blood Pressure readings for 342 (65%) male subjects and 184 (35%) female subjects are noted in Table 2. Blood pressure readings at the higher levels are reported for the male subjects more often than the female subjects in the study.
The self-reported weights of the subjects reflected in Table 3 indicate that weight is a factor associated with an increase in blood pressure readings. While there is a close correlation of weight and blood pressure readings, it is not highly significantly different. The mean was 2.46 on a total population of 494; standard deviation of 0.55.
While obesity may not be a significant factor among the elderly, the aftermath of changes associated with obesity in the earlier years may be a factor calling for additional study.
There were 488 subjects who responded to the question about knowledge of hypertension condition. Of this number, 330 (70%) responded affirmatively; 158 (30%) did not know of their hypertension.
Knowledge of medication regimen was responded to affirmatively by 140 of the subjects. No statistically significant difference was found in the analysis of association between knowledge of medication and blood pressure readings.
DIASTOLIC AND SYSTOLIC READINGS
SEX AND SYSTOLIC AND DIASTOLIC BLOOD PRESSURE READINGS
WEIGHT AND BLOOD PRESSURE READINGS
Self-reported activity levels of the 499 subjects were noted as active by 230 subjects and moderately active by 252 subjects. Seventeen reported a sedentary life style. There was no significant difference in the association of activity with blood pressure readings.
Finally, 517 subjects responded to items on smoking. Of that number, 193 identified themselves as smokers and 324 as non-smokers; ninty-one said they smoked more than one pack of cigarettes a day and 94 smoked less than one pack a day. Although no statistical significance was computed, there remains some question about the possible relationship between smoking and blood pressure readings.
Limitations of the Study
Limitations of this study include the following:
1. Data collected in community settings by a variety of health personnel, including trained volunteers.
2. Incomplete data resulted in a variation of the number of subjects for each variable being stuthed.
3. Questionnaire deficiency in that items such as weight, level ol activity, and amount of cigarettes smoked were not clearly delineated by criteria.
4. Self-reporting on questionnaire without clarification of items to be completed to avoid ambiguity or misinterpretation.
Implications for Nursing
This descriptive study reflects findings from which further research questions should be formulated and additional stuthes conducted. Additional information is needed on blood pressure readings and relationships to selected parameters among elderly individuals in community settings. Although the null hypothesis was not supported by significant findings in each of the variables stuthed, some trends were identified that could demonstrate an influence on the health status, e.g., blood pressure, weight, age of the elderly individual.
The discovery of the use of an arbitarily set norm for blood pressure elevation as the basis for instituting medication protocol for elderly, ambulatory subjects pointed out the need for furtlier study. Findings suggest other variables in the life style of the older person that may be adaptive in nature and that may influence the blood pressure reading.
Health professionals should have knowledge and skills in history taking requisite to the needs of older persons. Identification of factors that may influence the health status of the individual being interviewed is of key importance. Accuracy is crucial since decisions for care and treatment are based upon the data collected. Beyond this, there is need for knowledge of norms that apply to an elderly, ambulatory population, such as blood pressure readings.
Findings of British researchers indicate a higher reading of systolic and diastolic blood pressure than those commonly used as the norm in the United States.2 These readings are not considered pathological in the healthy, ambulatory elderly British population.
Perhaps attention should be directed first toward assisting the older person to modify behavior and environment rather than to take medication in an attempt to control blood pressure and maintain health status. If medical regimen is indicated, careful monitoring for changes such as postural hypertension and decreased potassium levels would be indicated based upon the prescribed medications.
Recommendations for Further Study
1. Replicating this study with a larger sample conducted by health professionals especially prepared for the task.
2. Conducting stuthes to further explore the effect of thet, smoking, activity, and weight control on the blood pressure measurements of an elderly, ambulatory population.
3. Designing a standardized health teaching plan for elderly, ambulatory individuals that would promote a state of health and well being through behavioral and environmental modifications.
4. Implementing longitudinal stuthes to establish norms of blood pressure readings and the relationship between selected parameters of importance to an ambulatory elderly population.
This descriptive study, which investigated the relationship between blood pressure readings and selected parameters in an elderly ambulatory population, revealed trends that indicate need for further study. The physiological phenomenon comprising the blood pressure mechanism within an aging adult is a highly complex process. This process involves the individual's internal and external environment and, therefore, is subject somewhat to control. Projected recommendations for further study have been suggested. Too little is yet known about the norms of blood pressure readings for older persons and their ability to adapt to their environment. Perhaps education for selfcare is one facet of the multifaceted condition of hypertension that should receive further attention in the attempt to promote a state of well being among the elderly.
The authors express appreciation to Kalab Hassanein, PhD, Chairperson, Department of Biometry, University of Kansas, for statistical analysis of the data.
- 1. Sheehy TW: To treat or not to treat hypertension in the aged. J Med Assoc State Ala June 1977, pp 27-31.
- 2. Caird FI, Judge TG: Assessment of the Elderly Patient. Oxford, England, ' Alden and Mowbray Ltd, 1974, pp 3435.
- 3. Anderson F: Practical Management of the Elderly, ed 3. Philadelphia. JB Lippincott Company, 1976, p 24.
- 4. Kahn RT: Heart and cardiovascular system, in Finch CE, Hayflick L (eds): The Handbook of the Biology of Aging. New York, Van Nostrand Reinhold Company. 1977, pp 281-317.
- 5. Rahe RH: Subjects recent life changes and their near-future illness reports; Previous work and new directions of study, in Riehl JP, Roy C (eds): Conceptual Models for Nursing Practice. New York, Appleton -Cen tu ry-Crofts, 1974, pp 63-81.
- 6. Stamler R, Stamler J, Reidlinger WF, et al: Weight and blood pressure. Findings in hypertension screening of 1 million Americans. JAMA 240(15): 1607-1610, 1978.
- 7. Freis D: The mismanagement of hypertension, editorial. Arch Intern Med 137:1669. December 1977.
- 8. How you can help your doctor treat your high blood pressure. American Heart Association, 1977.
- 9. Master AM, Lasser RP: Blood pressure elevation in the elderly patient, in Brest AN, Moyer JH (eds): Hypertension. Second Hahnemann Symposium on Hypertensive Disease. Philadelphia, Lea and Febiger, 1964, ? 24.
- 10. Ward G: Changing trends in control of hypertension. Public Health Rep 931): 31-34. 1978.
DIASTOLIC AND SYSTOLIC READINGS
SEX AND SYSTOLIC AND DIASTOLIC BLOOD PRESSURE READINGS
WEIGHT AND BLOOD PRESSURE READINGS