Coronary heart disease (CHD) and cerebrovascular disease, both of which are atherogenic diseases, cause more death, disability, and economic loss in the United States than any other disease (American Heart Association, 1999). The incidence of almost all cardiovascular diseases increases with advancing age, emphasizing the need for cardiovascular risk assessment and health promotion efforts in elderly individuals.
Several risk factors have been linked to the presence or acceleration of the atherogenic process in elderly individuals. Modifiable risk factors that affect the prognosis for an individual with, or at risk for, cardiovascular disease include:
* Lifestyle influences (e.g., cigarette smoking, sedentary lifestyle, poor dietary patterns, obesity).
* Atherogenic personal traits (e.g., hypertension, hyperlipidemia, diabetes mellitus, psychosocial factors).
Reduction or elimination of these risk factors has been linked to a reduced death rate from cardiovascular disease and stroke and regression of atherogenic lesions (Vokonas & Kannel, 1996). Nonmodifiable risk factors that affect the prognosis for an individual with CHD are family history, age, and gender.
The recent decline in deaths due to CHD are thought to be partially related to changes in lifestyle, improvement in health behavior, and improved management of atherogenic traits. Application of lifestyle changes and therapeutic interventions can lessen morbidity and mortality in elderly individuals and can be most beneficial in elderly individuals at high risk for CHD (Wenger, 1993). This article provides a review of the salient cardiovascular risk factors in elderly individuals, with an emphasis on lifestyle changes as the primary, nurse-guided interventions.
MODIFIABLE RISK FACTORS
Blood Pressure and Hypertension
Hypertension is one of the most potent risk factors for all cardiovascular complications. Elevated blood pressure is the major factor underlying strokes and is a primary cause of myocardial infarction (MI) and cardiovascumortality. Hypertension is defined as a diastolic blood pressure of 90 mm Hg and higher. Both systolic and diastolic blood pressure are related to cardiovascular risk. Treatment of mild to moderate hypertension has shown significant reduction in risk for cardiovascular mortality and cerebrovascular accidents (Hebert, Moser, Mayer, Glynn, & Hennekens, 1993). A recent meta-analysis which included individuals age 60 and older demonstrated antihypertensive therapy significantly improves survival and decreases stroke and cardiac mortality and morbidity (Insua et al., 1994).
Despite the clinical emphasis on diastolic hypertension, epidemiologic data substantiates the risk for CHD associated with elevations in systolic blood pressure (Vokonas & Kannel, 1996). Isolated systolic hypertension accounts for 65% of hypertension in elderly individuals (Joint National Committee QNC] VI, 1997). Thus, attention to systolic blood pressure may be particularly important for elderly individuals. Treatment of isolated systolic hypertension in elderly individuals has been shown to decrease nonfatal infarction, left ventricular failure, and stroke over 4.5 years (SHEP Cooperative Research Group, 1991).
Appropriate assessment of elderly individuals with hypertension includes a thorough medical history, including duration of elevated blood pressure; family history of elevated blood pressure and heart disease; smoking or tobacco use; and dietary assessment, including intake of sodium and saturated fats. A history must be recorded of all medication use and psychosocial and environmental factors that may influence blood pressure control QNC VI, 1997). The physical examination should include serial blood pressure measurements separated by 2 minutes, with the individual supine or seated, and after standing for at least 2 minutes, with verification in the contralateral arm. In addition, a funduscopic examination, and examination of the heart for rhythm abnormalities, murmurs, extrasystoles, the extremities for diminished or absent pulses, and the lungs for bronchospasm or adventitious sounds should be performed.
Cigarette smoking is an independent and significant risk factor for the development of CHD. Smoking confers a two-fold to six-fold increased risk of both CHD and nonfatal MI, compared to never smoking (LaCroìx, Guralnik, Berkman, Wallace, & Satterfield, 1993). Individuals who quit smoking have lower death rates than people who continue to smoke. In addition, cigarette smoking acts synergistically with other risk factors to greatly increase the risk for CHD in elderly individuals.
TREATMENT OF HYPERTENSION IN ELDERLY INDIVIDUALS
Transient cardiovascular responses in healthy people include increased heart rate and blood pressure, cardiac stroke volume and output, and coronary blood flow. Concentrations of free fatty acids, glycerol, and lactate are increased. Carbon monoxide from cigarette smoke also produces cardiovascular effects including hypoxia of the intima and an increase in endothelial * permeability. Increased platelet aggregation, increased platelet adhesiveness, shortened platelet survival, decreased clotting times, and an increased hematocrit have been recorded in individuals who smoke (Müller, Abela, Nesto, & Toiler, 1994). Smoking cessation confers benefits regardless of gender, age, or presence of CHD. Smoking status should be assessed in all patients in the primary care setting, and smoking cessation should be encouraged among all patients.
Increases in body weight resulting in obesity represent an important risk factor for cardiovascular disease in elderly individuals. Obesity is a major health problem in the United States, particularly among elderly individuals. Body fat distribution, excess weight, and obesity are independent predictors of cardiovascular disease in some populations (McGinnis & BallardBarbash, 1991). Among 5,209 men and women of the original Framingham cohort, obesity was a significant independent predictor of cardiovascular disease, particularly among women (Hubert, Feinleib, McNamara, & Castelli, 1983). Increases in body weight have been associated with cardiovascular risk factors including elevated blood pressure, increased serum cholesterol and triglyceride levels, and increased blood glucose levels. Obesity is associated with an atherogenic lipoprotein profile (National Research Council, 1989). Obesity has been negatively related to high-density lipoprotein cholesterol (HDL-C) 2 and HDL-C3, and positively correlated with plasma total cholesterol, low-density lipoprotein cholesterol (LDL-C), and triglyceride levels (Grundy et al., 1997). Kännel (1990), reporting Framingham data, estimates that, in women, for each percent increase in relative weight, there was predicted a .6 mg/dL increase in serum cholesterol.
ASSESSMENT OF SERUM LIPID VALUES
Patterns of increased abdominal or truncal obesity have been associated with hypertension, hyperlipidemia, insulin resistance, very lowdensity lipoprotein cholesterol (VLDL-C) and triglycerides, and low concentrations of HDL cholesterol, all of which increase cardiovascular risk (Reaven, 1993). Further, abdominal obesity has been associated directly with cardiovascular morbidity and mortality (Garrison, Higgins, & Kannel, 1996).
Evaluation and management of obesity is important, and to minimize the risk of CHD, elderly individuals need to attain and maintain an optimal body weight. The lifestyle patterns related to obesity include dietary intake in excess of metabolic requirements, sedentary activity patterns, and undesirable eating patterns.
The role of physical activity and physical fitness in preventing and controlling CHD is well established. Recent studies suggest that even moderate physical activity on a regular basis confers cardiopulmonary conditioning benefits (United States Department of Health and Human Services, 1996). Regular physical activity reduces CHD risk, promotes weight loss and control, and improves musculoskeletal functioning (Paffenbarger, Jr. et al.,1993). Data from several epidemiologic studies suggest that populations with habitual physical activity have decreased mortality from atherogenic CHD. The Framingham data showed improved cardiovascular and CHD mortality rates with increased physical activity at all ages, including elderly individuals. Physiologic benefits of regular physical activity are related to increased HDL cholesterol levels, reduction in blood pressure, increased cardiovascular functional capacity, decreased myocardial oxygen demand, lowered plasma insulin levels with improved glucose tolerance, and a decrease in platelet adhesiveness and fibrolytic activity.
Serum Lipids and Lipoprotein
Dyslipidemia is a major risk factor in the development and severity of CHD. Increased risk is seen in individuals with elevated total cholesterol, triglycerides, LDL-C, and low levels of HDL-C. The ratio of HDL-C fraction to the LDL-C fraction may be of greater significance than either level alone for prediction of CHD (Stampfer, Sacks, Salvini, Willett, & Hennekens, 1991). Despite some conflicting evidence, cholesterol does appear to be a risk factor for elderly individuals (Hulley & Newman, 1994; Krumholz et al.,1994; Manolio et al., 1992). Although the direct evidence is strongest in middle-aged men with high initial cholesterol levels, epidemiologic data support the generalization that reducing total and LDL-C levels are likely to reduce CFTD incidence in older men and women.
Lowering cholesterol levels has been shown to reduce the incidence of CFiD events. It is estimated that each 1% reduction in serum cholesterol is associated with an approximate 2% reduction in coronary risk (Lipid Research Clinics Program, 1984; Stamler, Wentworth, & Neaton, 1986). Similarly, each 1% increase in HDL cholesterol has been associated with a 2% to 3% decrease in risk (Gordon et al., 1989).
The initial risk assessment based on lipid values includes measures of total cholesterol and HDL-C. The Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Sempos, 1993) recommends measurement of serum total cholesterol in all adults at least once every 5 years. When assessing the risk for elderly individuals with elevated lipids, it is important to remember the presence of known CHD or peripheral vascular or cerebrovascular disease places elderly individuals at increased risk.
Cholesterol reduction can be achieved by lifestyle changes including dietary therapy, weight loss, and physical activity, as well as a combination of lifestyle changes and pharmacologic therapy. People without HDL-C levels or severe dyslipidemias should be continued on dietary therapy for at least 6 months before considering drug therapy. Modification of associated risk factors such as obesity, sedentary lifestyle, and smoking should be maintained throughout cholesterollowering therapy. If the goals of LDL-C reduction are met by dietary modification, long-term monitoring is indicated. If reduction of LDL-C is not achieved, lipidlowering drugs are considered, along with continued diet and exercise therapy (Adult Treatment Panel II, 1996).
Treatment goals for pharmacologic therapy are the same as those for dietary therapy. Both treatment modalities attempt to achieve LDLC levels of less than 160 mg/dL in patients without diagnosed CHD or two associated CHD risk factors, or LDL-C levels of less than 130 mg/dL in patients with diagnosed CHD or two associated CHD risk factors.
TREATMENT OF HYPERLIPEMIA IN ELDERLY INDIVIDUALS
Diabetes mellitus affects 8 to 10 million Americans. Approximately 12% of individuals older than age 65 have diabetes mellitus. It is one of the leading causes of disability in those older than age 45. Coronary heart disease represents the ultimate cause of death in more than half of individuals with diabetes and tends to occur at an earlier age and with greater severity than in the nondiabetic population (Birch & Green, 1997).
Accelerated atherogenesis is a major complication of diabetes mellitus. Accelerated atherogenesis may be related to factors such as hyperglycemia, hyperinsulinernia, and plasma lipid abnormalities, all of which are common in individuals with diabetes. Data demonstrate CHD risk factors tend to cluster in individuals with diabetes. Individuals with diabetes are more likely to be obese and hypertensive, and have abnormal lipid profiles. Hyperglycemia is considered to be an independent risk factor in the development of CHD in individuals with diabetes. Increased blood glucose is associated with increased plasma lipid levels, elevated mean systolic and diastolic blood pressures, and a higher mean body mass. Accelerated atherogenesis in individuals with diabetes mellitus indicates an alteration in both lipid and lipoprotein metabolism. Elevation of VLDL concentrations occurs frequendy in insulin-dependent diabetics, resulting in increased total plasma cholesterol and triglyceride levels.
The relationship between glycémie control and plasma cholesterol and triglyceride levels may be significant in altering the predicted risk of CHD in individuals with non-insulin-dependent diabetes. Although both men and women who have non-insulin-dependent diabetes have lower HDL-C levels than control subjects without diabetes, the relative decrease is greater for women (Levy & Kannel, 1988). Another potential risk factor for CHD in individuals with diabetes is the level of circulating insulin. Hyperinsulinemia promotes ischemic vascular disease and is a risk factor independent of blood glucose level, plasma cholesterol, and blood pressure. Because the precursor stages of Type II diabetes are characterized by hyperinsulinemia, individuals may be exposed to increased circulating insulin levels over time. Hyperinsulinemia is prevalent in individuals with Type II diabetes secondary to insulin resistance related to obesity.
Because the control of hyperglycemia alone does not appear to reduce the risk of microvascular sequelae in individuals with diabetes mellitus, attention must be directed toward the management of associated cardiovascular risk factors. Risk reduction in individuals with diabetes must begin with an assessment of needs and education related to the diabetic process and the role of associated risk factors. The primary factor in reduction of cardiovascular risk is dietary control. In elderly individuals with diabetes, caloric restriction combined with intake alteration can significantly decrease plasma insulin, triglycerides, total cholesterol, VLDL-C, and elevated blood pressure; increase HDL-C levels; and aid in glycémie control. American Diabetes Association (1995) guidelines for dietary modification urge reduction in saturated fat and cholesterol intake and increased intake of dietary fiber and complex carbohydrates.
Incidence of CHD cannot be explained completely by the major CHD risk factors. Considerable evidence suggests psychosocial and environmental factors may be independent predictors of CHD incidence in population studies (Berkman, Leo-Summers, & Horwitz, 1992; Kaplan, 1997). These factors include coronary prone behavior, low socioeconomic status, and social isolation.
Coronary Prone Behavior
Several studies have identified the Type A behavior pattern, which includes impatience, aggressiveness, and competitiveness, as a risk factor for CHD. Data from the Framingham study suggests that women with Type A personalities are at increased risk for the development of heart disease (Haynes & Feinleib, 1980). However, the relationship between Type A behavior pattern and CHD morbidity and mortality continues to be debated. Some evidence indicates the anger and hostility components may be more important predictors of cardiovascular outcome (Williams, 1987). The ability to express anger may be of particular importance in women (Eaker, 1989). More recent studies document a significant relationship between hostility and perfusion defects among women and middle-aged men (Helmers, Krantz, Howell, Klein, Bairey, & Rozanski, 1993).
Lower socioeconomic status has been documented as a factor associated with increased CHD mortality in both men and women. Research examining the relationships among behavioral risk factors for CHD and socioeconomic characteristics has identified direct relationships between the practice of risk-reducing behaviors and level of income, education, and occupational status (Stason, 1 990; Wing, Casper, Riggan, Hayes, & Tyroler, 1988).
Low levels of social support, weak social connections, and social isolation have been related consistently to adverse health outcomes. A high level of social support has been associated with decreased cardiac mortality, enhanced physical and psychosocial function, and adherence to risk modification (Dracup, 1994; Moser, 1994; Riegel, 1989). Social isolation has been associated consistently with an increase in mortality rates from CHD (Berkman et al., 1992; Kaplan, 1997; Seeman & Sy me, 1987). Elderly individuals identified to be at highest risk for mortality from CHD are those who live alone and are socially isolated.
NONMODIFIABLE RISK FACTORS
The risk for CHD rises sharply with age in all populations studied. The widely held belief that risk factors decrease in importance with age is inaccurate. Rather, evidence suggests there is no age beyond which modification of risk factors will not confer a positive benefit in reduction of cardiovascular risk (Manolio et al., 1992).
In the United States, CHD becomes evident at approximately age 40, with the incidence increasing significantly after age 45 in men and age 55 in women. The rate of increase in CHD mortality is linear for men, whereas in women the rate of increase is less before menopause. For women, the incidence of CHD increases rapidly following menopause. Eighty percent of all MI deaths occurring in individuals older than age 65 (Wenger, 1993).
In the United States, the ageadjusted death rates for CHD in men are twice as high as for women. Despite the differences between men and women, CHD is the number one cause of death in women after age 60. High-density lipoprotein cholesterol has been identified as a more significant predictor of CHD risk in women than in men. In older postmenopausal women, triglyceride levels have been shown to independently predict CHD risk (LaRosa, 1992). Women up to age 64 are more vulnerable to risk factors of systolic blood pressure, blood glucose, and excess weight than men.
Coronary heart disease appears to aggregate strongly among family members. First-degree relatives of individuals with early-onset CHD are at higher risk for developing CHD, compared to the general population (Hopkins & Williams, 1989). Both genetic and environmental factors may increase family susceptibility to atherogenesis. Genetic susceptibility has been demonstrated in animal studies and through the identification of genetic and clinical markers in humans (Hobbs, Brown, & Goldstein, 1992; Williams et al., 1990). Genetic factors have been identified related to lipoprotein metabolism (LaRosa & Cleeman, 1992; Nishina, Johnson, Naggert, & Krauss, 1992). Familial combined hyperlipidemia is the most common syndrome found which corresponds to familial CHD (Williams et al., 1990). Elevated fibrinogen level has been identified as an independent CHD risk factor (Hopkins & Williams, 1989). Environmental factors such as smoking, patterns of physical activity, and dietary intake have been correlated significantly between spouses as well as among other family members, and may reflect the shared family environment (Hunt, Williams, & Barlow, 1986).
The challenge of health promotion and disease prevention requires researchers and clinicians to explore new ways to address the problem of cardiovascular risk reduction in elderly individuals. The most important lifestyle behaviors that affect cardiovascular health in elderly individuals are presented in this article. Primary care practitioners must begin to explore the most effective techniques for promoting sustained cardiovascular risk-reducing behaviors in older adults.
The importance of thorough and appropriate assessment for cardiovascular risk in elderly individuals cannot be overemphasized. The process and content of interventions for elderly individuals is much different than for younger individuals. The window of opportunity for behavior change and screening efforts in elderly individuals may be quite narrow. Physical and physiological changes accompanying aging may leave little opportunity for significant changes in health outcomes following health behavior changes, but the evidence remains that there are large risk reduction gains achieved with small changes in systolic blood pressure reduction and use of hormone replacement therapy, for example.
The rapid increase in numbers and proportions of older individuals with diverse ethnic origins necessitates targeting interventions toward an appropriate cultural context. In later years of life, minority elderly individuals, more than other groups, face older age with a lifetime of racial discrimination, marginal living conditions, and quality of life inequities. Interventions should be designed with the target ethnic or racial group in mind and should include individual variations in communication, family and kinship, and resources.
Individual, community, and social changes are necessary to overcome significant risk factors for cardiovascular risk in elderly individuals, including traditional risk factors, inadequate financial resources, environmental stresses, lack of access to health care, and social isolation. Nurses must begin to explore with elderly individuals the potential solutions to individual, community, and system-wide problems to better understand "risk" within a larger context and to develop more effective and relevant community interventions. Thus, for each intervention or prescription for change in nutritional, exercise, or other risk factor profile, clinical assessments of elderly individuals' functional capabilities must be performed. Assessment of their environment in terms of safety, resources, and social support to sustain behavioral changes needs to be considered.
The importance of lifestyle changes in achieving cardiovascular risk reduction is critical. There is evidence that there are large risk reduction gains achieved with small changes in such risk factors as systolic blood pressure reduction. Clinicians and researchers who are committed to prolonging life and targeting quality of life issues need to be knowledgeable about the assessment parameters surrounding cardiovascular risk factors in elderly individuals.
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TREATMENT OF HYPERTENSION IN ELDERLY INDIVIDUALS
ASSESSMENT OF SERUM LIPID VALUES
TREATMENT OF HYPERLIPEMIA IN ELDERLY INDIVIDUALS