Hypertension is reported to affect approximately 65 million individuals in the United States and nearly 1 billion worldwide, with expected increases as the average life expectancy rises (Fields et al., 2004; Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure [JNC], 2003). African American individuals have an earlier onset, higher prevalence, and greater rate of more complicated hypertension than White individuals (JNC, 1997). This disparity is reflected in the recent Third National Health and Nutrition Examination Survey (1988 to 1994) study results of Americans 65 to 84 years old (Sundquist, Winkleby, & Pudaric, 2001). African American men and women were found to have a higher prevalence of cardiovascular disease (CVD) risk factors, including hypertension, than the comparative sample of White individuals, after accounting for age and socioeconomic status. With heart disease and stroke as the first and third respective leading causes of death in the United States, compounded by the disproportionate effects of hypertension on older African American adults, nurses have a compelling challenge to provide preventative care to this vulnerable population.
Primary and secondary hypertension prevention programs that are ethnic and age sensitive must focus on this vulnerable population. Successful prevention programs may be pivotal antecedents to public policy change that could provide this group with needed resources, such as home blood pressure telemonitoring equipment (Artinian, Washington, & Templin, 2001). Gerontological nurses are in a primary position to support successful implementation of these hypertension prevention programs.
One way gerontological nurses can provide this support is by assessing elderly individuals with hypertension for cognitive impairment when engaging them in an intervention program using educational and behavioral change strategies. Cognitive assessment is important because elderly individuals are at high risk for cognitive impairment caused by the effects of age and hypertension on cognitive functioning. Undiagnosed cognitive impairment places elderly individuals at a greater health risk because it may inhibit their ability to successfully manage the treatment plan for hypertension control. Lack of awareness of a cognitive problem prevents health professionals from planning appropriate intervention strategies for cognitively impaired individuals.
This article addresses the importance of cognitive assessment in older individuals through exploring the effect of hypertension and aging on cognition. Age and ethnically sensitive assessment tools are recommended for use in clinical practice with vulnerable populations, such as elderly African American individuals. It is suggested that a caring and ethnically sensitive approach to cognitive assessment can enhance its success. Practice implications highlight the major role gerontological nurses have in understanding and evaluating the effect of impaired cognition on successful management of hypertension.
HYPERTENSION AND COGNITION
A concise summary of research findings published during a 13 -year period (1987 to 2000) on hypertension and cognition, consisting of both longitudinal (range = 4 to 40 years) and cross-sectional designs, indicates strong support for the effects of both aging and hypertension on cognitive decline (Sidebar). Although it is beyond the scope of this article to review these findings in detail, the exact mechanism by which hypertension results in the cognitive decline found in these studies remains elusive. It is thought that the cognitive decline may be mediated by age because the specific areas at risk for decline with hypertension are remarkably similar to those encountered with cognitive aging.
Methodological concerns include the diverse cognitive measurement tools and minimal reporting of test cut-off scores and normative data, varied techniques in blood pressure measurements and reporting, and failures to completely report the participants' ethnic origins. Only Madden and Blumenthal (1998) identified a sampling category of 12% community-dwelling African American adults. Consequently, caution is needed when generalizing these results to an ethnically diverse population.
AGING AND COGNITION
Technological advancements in brain imaging and activation studies in cognitive aging have resulted in support of the concept that different components of the brain age at a different rate, both structurally and functionally (Raz, 2000). Raz indicates that working memory, speed of information processing, and executive functions (i.e., problem solving and flexible goalsetting behaviors) are moderately to substantially affected by aging. This effect on what is considered complex cognitive function may be caused by a combination of general age-related brain volume decline and decreased activation of the prefrontal cortex structures. Raz identifies the prefrontal cortex structures as one of the first structures to demonstrate the effects of aging.
Understanding these findings can help nurses recognize the initial subtle changes in behavior representative of cognitive decline, and anticipate the need for tailoring the nursing intervention. The cognitive functions affected by hypertension and aging are responsible for much of the complex cognitive work involved in everyday living. Medication, diet, and physical activity treatment adherence are examples of everyday living tasks that are often required for successful hypertension management and that make a high demand on cognitive capacity (JNC, 1997). When elderly individuals are confronted with complex cognitive tasks, such as the problem solving and goal-setting tasks often associated with management of a chronic illness, the presence of cognitive decline may put them in a vulnerable position.
COMPLEX COGNITION AND COGNITIVE ASSESSMENT
A review of the sequence of cognitive events believed to be involved in a complex cognitive task promotes appreciation for the functional areas in need of cognitive assessment. Adherence to a medication regimen requires individuals to comprehend the medication instructions, integrate the instructions through the use of working memory, remember the plan through the use of longterm memory, and remember to take the medication through the use of prospective memory (Park & Gutchess, 1999). It is suggested that this same sequence of cognitive events may be equally important in adherence to other therapeutic regimens, such as dietary modification or physical activity.
USE OF THE TRIARCHIC THEORY OF HUMAN INTELLIGENCE (STERNBERG, 1988) TO SELECT THE COGNITIVE DIMENSION OF INFORMATION PROCESSING TO GUIDE ASSESSMENT TOOL SELECTION
The complex cognitive functions involved in adherence to therapeutic regimens represent those previously demonstrated to be most at risk for decline with hypertension and aging. Therefore, the use of a complex cognitive theory to guide the selection of cognitive assessment tools is appropriate. One such theory, Sternberg's Triarchic Theory of Human Intelligence, was developed with the intent of providing an alternative to previous culturallydependent models of intelligence (Sternberg, 1988). Therefore, it is appropriate for use with elderly individuals with varied educational and socioeconomic characteristics. In Sternberg's theory, intelligence is viewed in terms of its information processing components that ultimately allow adaptation and shaping of an individual's immediate personal environment (Table 1).
Hypertension treatment often requires adjustments to an individual's physical and social environment to support lifestyle changes. These adjustments require intact information processing function. Three cognitive domains considered critical in information processing include memory, fluency, and orientation (Lichtenberg, 1998). In addition, memory has been shown to provide the best discrimination between patients with normal cognitive function and patients with early stage dementia (Lichtenberg, 1998; Perry & Kay, 1997). Therefore, these cognitive domains were used to guide the selection of appropriate measurement tools to assess cognitive function in elderly individuals with hypertension.
COGNITIVE ASSESSMENT TOOL SELECTION
Additional considerations in selection of an appropriate measurement tool of cognitive function for ethnically diverse populations of elderly individuals with hypertension are age and ethnic sensitivity, available normative data for comparisons, ease in administration, and flexibility for use in a variety of settings by the nurse. With these considerations in mind, two tools for assessment are recommended (Table 2) - the FuId Object-Memory Evaluation, and the MacNeill-Lichtenberg Decision Tree (FuId, 1982; MacNeill & Lichtenberg, 2000). These measurement tools can be administered easily in approximately 20 minutes, have been used in a variety of settings, are readily available, and require minimal nurse training. In addition, normative data are available, and use with a diverse ethnic population has been established (Wall, Deshpande, MacNeill, & Lichtenberg, 1998).
RECOMMENDED COGNITIVE ASSESSMENT TOOLS
A CARING APPROACH TO COGNITIVE ASSESSMENT
Prior to performing an assessment, it is important for nurses to anticipate the individual's and family's response to the cognitive assessment process. When the elderly adult with hypertension is African American, an understanding of African American culture related to caring is essential. In a review of clinical research conducted between 1996 and 2000 on the racial, ethnic, and cultural differences in the dementia caregiving experience, 21 intervention studies were identified involving African American adults (Janevic & Connell, 2001). Janevic and Connell found caregivers of African American adults were less likely to be a spouse, and more likely to be a younger relative than were caregivers of White adults. Frequently, this relative had dual responsibilities of employment and family care.
This finding is supported by a more recent study comparing caregiving experiences of White and African American female informal caregivers for home-bound elderly adults (Cuellar, 2002). Cuellar found the White caregivers were usually spouses, and the African American caregivers were adult daughters. In recognizing the diversity of family caregiving experiences across and within ethnic groups, five key questions formulated from caregiving issues identified by Cuellar are important to consider prior to performing a cognitive assessment:
* Is there evidence of caring for this individual within the family structure?
* How is this commitment to care (caregiving) expressed by the family?
* Who is the caregiver and the care receiver in the family?
* Has the caregiver verbalized a perception of a burden?
* Is the caregiver displaying evidence of stress or strain?
After the answers to these questions have been considered, the nurse can better understand the meaning of the cognitive assessment to the family. The nurse must be prepared to accept that some individuals within the family may view cognitive assessment as a threat. Cognitive assessment may prompt caregivers to explore the meaning of dementia as captured in one group of cross-cultural caregivers' descriptive statements, equating dementia to a "loss of identity" and "a loss of self" (Janevic & Connell, 2001).
In Bowers' (1987) description of five categories of intergenerational caregiving, protective caregiving was provided when threats to the parents' self-image and the parent-child relationship were encountered, such as with cognitive decline. Bowers found if the nurse did not accurately assess these dynamics, resulting conflicts could quickly place the nurse in an adversarial role. A great deal of stress is ascribed to a protective role, which is a health hazard to the care receiver with cognitive decline. When nurses encounter a mutually reinforcing system of denial in the caregiving dyad, counseling to promote an awareness of the destructive elements of this continued pattern is often required before support for the cognitive assessment is obtained.
The recognition of cognitive decline by the caregiving dyad may be associated with other concerns. The additional burden of caring for a cognitively impaired and chronically ill older individual may be felt as the caregiver anticipates the need for increased assistance with activities of daily living (Faison, Faria, & Frank, 1999). Prior patterns of engagement and detachment allowing the caregiver to successfully cope may need to be adjusted (Carmack, 1997). An identified cognitive impairment in the care receiver may require more resource commitment than the caregiver can provide.
The extent to which the caregiving dyad support the concept of "familism" is important for the nurse to consider. The concept of familism in African American culture relates to an obligation for caring that is a primary motivator for the caregiver. The caregiver's needs are considered to be of secondary importance. Differences in the perception of the caregiver's responsibilities may be a source of conflict that further strain the relationship if a cognitive impairment is identified.
The nurse can anticipate that the care receiver may also be apprehensive about the cognitive assessment. An individual with mild cognitive impairment may be fearful of loss of independence and lower self-esteem. The caregiving dyad may be apprehensive that a "label" will be applied to behaviors previously dismissed as "normal" for the individual.
In contrast to the perception of the cognitive assessment process as a threat, some families may view it with welcome relief. In a small qualitative study in a Western metropolitan area, family caregiving at home was described as a "solitary journey" with burdens in emotional, physical, financial, and psychosocial areas (Boland & Sims, 1996). There is a common misconception that extensive social networks of support are available for ethnic minorities. Although social support networks may be available, they may be less than optimal for some elderly individuals in the ethnic minority. Johnson and Tripp-Reimer (2001) found both immediate and non-immediate family members were involved in caregiving activities to maintain African American individuals with cognitive impairment at home, and that some of the older individuals may not perceive this care as adequate. In this situation, the cognitive assessment may provide the family with information that can support the need for additional professional assistance.
Demonstration of the FuId Object Memory Evaluation.
It has been found that African American older individuals are not only admitted to nursing homes at half the rate of White older individuals, but also spend longer intervals in the community prior to admission (Janevic & Connell, 2001; Johnson & Tripp-Reimer, 2001). Nursing homes report the most common diagnostic category of its residents to be dementia, with cortical dementia known to cause a loss of awareness of the deficits in the middle and later stages (Lichtenberg, 1998). This is an ominous sign for community-dwelling African American adults who are mildly impaired and hypertensive whose caregivers are unaware of cognitive deficits.
Situating the cognitive assessment process within the context of the caregiving dyad's potential reactions, the nurse can proceed with an explanation of the rationale for the cognitive assessment to the caregiving family. The nurse can communicate to the family that the cognitive assessment allows the use of appropriate interventions to achieve mutually agreed upon goals of blood pressure management. This approach will assist the patient in maintaining a sense of control over the process.
Once the cognitive assessment has been completed, strategies for intervention diverge based on the presence of suspected cognitive impairment. Because the purpose of the assessment is to screen for adequacy of functioning in cognitive domains essential for successful hypertension management, individuals who perform poorly on the screening tests should be referred to their primary care provider for further neuropsychological evaluation. Further hypertension education and lifestyle behavioral strategies will need to be appropriately tailored to level of cognitive functioning. For the cognitively intact individuals, the nurse can proceed with education and counseling (JNC, 1997).
Hypertension morbidity and related mortality rates, combined with the effects of normal aging and hypertension on cognition, place older adults with hypertension in a vulnerable position. Typical lifestyle change strategies necessary for blood pressure control may be beyond their capacity to understand and implement in the presence of undiagnosed cognitive decline. Therefore, cognitive functioning is a primary consideration when engaging older adults with hypertension in intervention programs focused on educational and behavioral change strategies.
Lack of awareness of a cognitive problem prevents health professionals from planning appropriate intervention strategies with cognitively impaired individuals. Identifying cognitive impairment through the use of appropriate cognitive assessment early in the interaction can assist nurses in tailoring interventions. Interventions can be designed to assist individuals to manage their hypertension according to their cognitive ability.
With future research aimed at minority caregivers determined as a priority (Farran, 2001), successful caring and ethnically sensitive approaches to early cognitive assessment of older African American adults with hypertension need to be identified and studied in community settings. The gerontological nurse, through understanding and evaluating the effect of impaired cognition on successful management of hypertension, can provide a pivotal role in improving the quality of life of this vulnerable population.
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USE OF THE TRIARCHIC THEORY OF HUMAN INTELLIGENCE (STERNBERG, 1988) TO SELECT THE COGNITIVE DIMENSION OF INFORMATION PROCESSING TO GUIDE ASSESSMENT TOOL SELECTION
RECOMMENDED COGNITIVE ASSESSMENT TOOLS