Question

The community health nurse is preparing a program about hypertension for a local community center. The focus of the program is on the reduction of risk factors and compliance for those who have been diagnosed with high blood pressure. The target population includes older adults.

a.The nurse focuses on primary hypertension because it accounts for 90% - 95% of hypertension in the United States. What risk factors does the nurse include for this population?

Smoking, elevated LDL’s and total cholesterol, diabetes mellitus, impaired renal function, obesity, physical inactivity, age over 55, and family history of cardiovascular disease are all risk factors for high blood pressure.

b.The nurse prepares to discuss the changes in how the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure defines hypertension. What ranges and descriptions should the nurse include?

c.Because this is a gerontologic audience, the nurse needs to review why blood pressure increases with age. Explain how the structural and functional changes of aging contribute to higher blood pressure in the older adult.

d. What information does the nurse include about lifestyle modifications that may decrease risk of hypertension or complications associated with diagnosed hypertension?

Answer 1

A - RISK FACTORS

*   Family history If your parents or other close blood relatives have high blood pressure, there is an increased chance of getting it.

• Age The older you are, the more likely you are to get high blood pressure. As we age, our blood vessels gradually lose some of their elastic quality, which can contribute to increased blood pressure. However, children can also develop high blood pressure. Learn more about children and high blood pressure.
• Gender Until age 64, men are more likely to get high blood pressure than women are. At 65 and older, women are more likely to get high blood pressure. Learn more about women and high blood pressure.
• Race African-Americans tend to develop high blood pressure more often than people of any other racial background in the United States. It also tends to be more severe in African Americans, and some medications are less effective in treating HBP in blacks. Learn more about African-Americans and high blood pressure.
• Chronic kidney disease (CKD) HBP may occur as a result of kidney disease. And, having HBP may also cause further kidney damage.

Modifiable risk factors

These are the risk factors you can change to help prevent and manage high blood pressure, including:

• Lack of physical activity: Not getting enough physical activity as part of your lifestyle increases your risk of getting high blood pressure. Physical activity is great for your heart and circulatory system in general, and blood pressure is no exception. Learn more about getting regular physical activity.
• An unhealthy diet, especially one high in sodium: Good nutrition from a variety of sources is critical for your health. A diet that is too high in salt consumption, as well as calories, saturated and trans fat and sugar, carries an additional risk of high blood pressure. On the other hand, making healthy food choices can actually help lower blood pressure. Learn more about improving your diet.
• Being overweight or obese: Carrying too much weight puts an extra strain on your heart and circulatory system that can cause serious health problems. It also increases your risk of cardiovascular disease, diabetes, and high blood pressure. Learn more about managing your weight.
• Drinking too much alcohol: Regular, heavy use of alcohol can cause many health problems, including heart failure, stroke and an irregular heartbeat (arrhythmia). It can cause your blood pressure to increase dramatically and can also increase your risk of cancer, obesity, alcoholism, suicide, and accidents. Learn more about alcohol, high blood pressure and the importance of moderation.
• Sleep apnea: Obstructive sleep apnea may increase the risk of developing HBP and is common in people with resistant hypertension.
• High cholesterol: More than half of people with HBP also have high cholesterol.
• Diabetes: Most people with diabetes also develop HBP.
• Smoking and tobacco use: Using tobacco can cause your blood pressure to temporarily increase and can contribute to damaged arteries. Secondhand smoke, exposure to other people’s smoke, also increases the risk of heart disease for nonsmokers. Learn more about quitting smoking.
• Stress: Stress is not necessarily a bad thing in and of itself. But too much stress may contribute to increased blood pressure. Also, too much stress can encourage behaviors that increase blood pressure, such as poor diet, physical inactivity, and using tobacco or drinking alcohol more than usual. Socioeconomic status and psychosocial stress can affect access to basic living necessities, medication, healthcare providers, and the ability to adopt healthy lifestyle changes. Learn more about managing your stress.

B - The key messages of this report are: in those older than age 50, systolic blood pressure (SBP) of >140 mmHg is a more important cardiovascular disease (CVD) risk factor than diastolic BP (DBP); beginning at 115/75 mmHg, CVD risk doubles for each increment of 20/10 mmHg; those who are normotensive at 55 years of age will have a 90 percent lifetime risk of developing hypertension; prehypertensive individuals (SBP 120–139 mmHg or DBP 80–89 mmHg) require health-promoting lifestyle modifications to prevent the progressive rise in blood pressure and CVD; for uncomplicated hypertension, thiazide diuretic should be used in drug treatment for most, either alone or combined with drugs from other classes; this report delineates specific high-risk conditions, which are compelling indications for the use of other antihypertensive drug classes (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta blockers, calcium channel blockers); two or more antihypertensive medications will be required to achieve goal BP (<140/90 mmHg, or <130/80 mmHg for patients with diabetes and chronic kidney disease); for patients whose BP is >20 mmHg above the SBP goal or 10 mmHg above the DBP goal, initiation of therapy using two agents, one of which usually will be a thiazide diuretic, should be considered; regardless of therapy or care, hypertension will only be controlled if patients are motivated to stay on their treatment plan. Positive experiences, trust in the clinician, and empathy improve patient motivation and satisfaction. This report serves as a guide, and the committee continues to recognize that the responsible physician's judgment remains paramount.

C- Reasons for why blood pressure increases with age

Arterial stiffness

Elastic arteries show 2 major physical changes with age. They dilate and stiffen. Aorta and the proximal elastic arteries dilate by approximately 10% with each beat of the heart in youth, while the muscular arteries dilate by only 3% with each beat. Such a difference in the degree of stretch can explain differences in aging between proximal and distal arteries on the basis of fatigue. Fracture of elastic lamellae is seen in the aorta with aging and can account for both dilations and for stiffening (through the transfer of stresses to the more rigid collagenous components of the arterial wall). Autopsy studies of perfusion-fixed human arteries have shown that thickening is mostly confined to intimal hyperplasia. The result is a stiff artery that has decreased capacitance and limited recoil and is thus unable to accommodate the changes that occur during the cardiac cycle. Furthermore, during systole, the arteriosclerotic arterial vessel exhibits limited expansion and fails to buffer effectively the pressures generated by the heart causing an increase in systolic BP (SBP). On the other hand, the loss of recoil during diastole results in a reduction in diastolic BP (DBP). Thus, aging even in normotensive individuals is characterized by an increase in pulse pressure, creating greater pulsatile stress on the arterial system. Arterial stiffness is not only a product of structural changes in the arterial wall but is also induced by endothelium-derived vasoactive mediators such as endothelin 1 and decreased bioavailability of nitric oxide (NO), which plays a key role in endothelial dysfunction. According to a meta-analysis, aortic stiffness expressed as aortic pulse wave velocity (PWV) is a strong predictor for future cardiovascular events and all-cause mortality. The relative risk of total cardiovascular events, cardiovascular mortality and all-cause mortality were 2.26, 2.02 and 1.90, respectively for high vs low PWV subjects. Aortic PWV is estimated noninvasively from the delay of pressure wave foot at the femoral site and from the distance traveled by the pulse. A typical value in a 20-year-old is 5 m/s and in an 80-year-old is 10-12 m/s (i.e., a 2, 4-fold increase over 60 years). In elderly individuals of 60-75 years old, aortic PWV value below 10 m/s can be considered as a normal value. Values of 10-13 m/s can be considered as “high normal” or “borderline”, whereas an aortic PWV above 13 m/s is frankly elevated. In contrast to younger patients with hypertension in whom elevated BP is determined primarily by increased peripheral arterial resistance, the isolated systolic hypertension seen in elderly people is due to increased arterial stiffness.

Neurohormonal and autonomic dysregulation

Neurohormonal mechanisms such as the renin-angiotensin-aldosterone system decline with age. Plasma renin activity at the age of 60 years is 40% to 60% of the levels found in younger individuals. This has been attributed to the effect of age-associated nephrosclerosis on the juxtaglomerular apparatus. Plasma aldosterone levels also decrease with age. Consequently, elderly patients with hypertension are more prone to drug-induced hyperkalemia. In contrast, net basal sympathetic nervous system activity increases with advancing age. Peripheral plasma norepinephrine concentration in the elderly is double the level found in younger subjects. The age-associated rise in plasma norepinephrine is thought to be a compensatory mechanism for the reduction in β-adrenergic responsiveness with aging.

Decreased baroreflex sensitivity with age causes orthostatic hypotension in the elderly. On the contrary, orthostatic hypertension, where BP increases with the postural change, is also prevalent among the elderly. The orthostatic hypertension is blocked by the α-adrenergic blockade, indicating that α-adrenergic activity may be a predominant pathophysiological mechanism.

The aging kidney

The aging kidney is characterized by progressive development of glomerulosclerosis and interstitial fibrosis, which is associated with a decline in GFR and reduction of other homeostatic mechanisms. Age-associated decline in activity of membrane sodium/potassium and calcium adenosine triphosphate pumps lead to an excess of intracellular calcium and sodium, thereby increase of vasoconstriction and vascular resistance. Increased salt sensitivity characterized by an increase in BP in response to sodium overload occurs in older and obese subjects as a result of the limited renal ability of these subjects to excrete sodium overload.

D - LIFESTYLE MODIFICATIONS

1. Shed extra kilos

Blood pressure often increases as weight increases. Being overweight also can cause disrupted breathing while you sleep (sleep apnea), which further raises your blood pressure.

Weight loss is one of the most effective lifestyle changes in controlling blood pressure. Losing even a small amount of weight if you're overweight or obese can help reduce your blood pressure. In general, you may reduce your blood pressure by about 1 millimeter of mercury (mm Hg) with each kilogram of weight you lose.

2. Exercise regularly

Regular physical activity — such as 150 minutes a week, or about 30 minutes most days of the week — can lower your blood pressure by about 5 to 8 mm Hg if you have high blood pressure. It's important to be consistent because if you stop exercising, your blood pressure can rise again.

If you have elevated blood pressure, exercise can help you avoid developing hypertension. If you already have hypertension, regular physical activity can bring your blood pressure down to safer levels.

Some examples of aerobic exercise you may try to lower blood pressure include walking, jogging, cycling, swimming or dancing. You can also try high-intensity interval training, which involves alternating short bursts of intense activity with subsequent recovery periods of lighter activity. Strength training also can help reduce blood pressure. Aim to include strength training exercises at least two days a week. Talk to your doctor about developing an exercise program.

3. Eat a healthy diet

Eating a diet that is rich in whole grains, fruits, vegetables, and low-fat dairy products and skimps on saturated fat and cholesterol can lower your blood pressure by up to 11 mm Hg if you have high blood pressure. This eating plan is known as the Dietary Approaches to Stop Hypertension (DASH) diet.

It isn't easy to change your eating habits, but with these tips, you can adopt a healthy diet:

4. Reduce sodium in your diet

Even a small reduction in the sodium in your diet can improve your heart health and reduce blood pressure by about 5 to 6 mm Hg if you have high blood pressure.

The effect of sodium intake on blood pressure varies among groups of people. In general, limit sodium to 2,300 milligrams (mg) a day or less. However, a lower sodium intake — 1,500 mg a day or less — is ideal for most adults.

5. Limit the amount of alcohol you drink

Alcohol can be both good and bad for your health. By drinking alcohol only in moderation — generally one drink a day for women, or two a day for men — you can potentially lower your blood pressure by about 4 mm Hg. One drink equals 12 ounces of beer, five ounces of wine or 1.5 ounces of 80-proof liquor.

But that protective effect is lost if you drink too much alcohol.

Drinking more than moderate amounts of alcohol can actually raise blood pressure by several points. It can also reduce the effectiveness of blood pressure medications.

6. Quit smoking

Each cigarette you smoke increases your blood pressure for many minutes after you finish. Stopping smoking helps your blood pressure return to normal. Quitting smoking can reduce your risk of heart disease and improve your overall health. People who quit smoking may live longer than people who never quit smoking.

7. Cut back on caffeine

The role caffeine plays in blood pressure is still debated. Caffeine can raise blood pressure up to 10 mm Hg in people who rarely consume it. But people who drink coffee regularly may experience little or no effect on their blood pressure.

Although the long-term effects of caffeine on blood pressure aren't clear, it's possible blood pressure may slightly increase.

To see if caffeine raises your blood pressure, check your pressure within 30 minutes of drinking a caffeinated beverage. If your blood pressure increases by 5 to 10 mm Hg, you may be sensitive to the blood pressure raising effects of caffeine. Talk to your doctor about the effects of caffeine on your blood pressure.

8. Reduce your stress

Chronic stress may contribute to high blood pressure. More research is needed to determine the effects of chronic stress on blood pressure. Occasional stress also can contribute to high blood pressure if you react to stress by eating unhealthy food, drinking alcohol or smoking.

Take some time to think about what causes you to feel stressed, such as work, family, finances or illness. Once you know what's causing your stress, consider how you can eliminate or reduce stress.

If you can't eliminate all of your stressors, you can at least cope with them in a healthier way. Try to:

• Change your expectations. For example, plan your day and focus on your priorities. Avoid trying to do too much and learn to say no. Understand there are some things you can't change or control, but you can focus on how you react to them.
• Focus on issues you can control and make plans to solve them. If you are having an issue at work, try talking to your manager. If you are having a conflict with your kids or spouse, take steps to resolve it.
• Avoid stress triggers. Try to avoid triggers when you can. For example, if rush-hour traffic on the way to work causes stress, try leaving earlier in the morning, or take public transportation. Avoid people who cause you stress if possible.
• Make time to relax and to do activities you enjoy. Take time each day to sit quietly and breathe deeply. Make time for enjoyable activities or hobbies in your schedule, such as taking a walk, cooking or volunteering.
• Practice gratitude. Expressing gratitude to others can help reduce your stress.

9. Monitor your blood pressure at home and see your doctor regularly

Home monitoring can help you keep tabs on your blood pressure, make certain your lifestyle changes are working, and alert you and your doctor to potential health complications. Blood pressure monitors are available widely and without a prescription. Talk to your doctor about home monitoring before you get started.

Regular visits with your doctor are also key to controlling your blood pressure. If your blood pressure is well-controlled, check with your doctor about how often you need to check it. Your doctor may suggest checking it daily or less often. If you're making any changes in your medications or other treatments, your doctor may recommend you check your blood pressure starting two weeks after treatment changes and a week before your next appointment.

10. Get support.

Supportive family and friends can help improve your health. They may encourage you to take care of yourself, drive you to the doctor's office or embark on an exercise program with you to keep your pressure low.

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COMPLICATIONS ASSOCIATED WITH HYPERTENSION

• Heart attack or stroke. High blood pressure can cause hardening and thickening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
• Aneurysm. Increased blood pressure can cause your blood vessels to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
• Heart failure. To pump blood against the higher pressure in your vessels, the heart has to work harder. This causes the walls of the heart's pumping chamber to thicken (left ventricular hypertrophy). Eventually, the thickened muscle may have a hard time pumping enough blood to meet your body's needs, which can lead to heart failure.
• Weakened and narrowed blood vessels in your kidneys. This can prevent these organs from functioning normally.
• Thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
• Metabolic syndrome. This syndrome is a cluster of disorders of your body's metabolism, including increased waist circumference; high triglycerides; low high-density lipoprotein (HDL) cholesterol, the "good" cholesterol; high blood pressure and high insulin levels. These conditions make you more likely to develop diabetes, heart disease, and stroke.
• Trouble with memory or understanding. Uncontrolled high blood pressure may also affect your ability to think, remember and learn. The trouble with memory or understanding concepts is more common in people with high blood pressure.
• Dementia. Narrowed or blocked arteries can limit blood flow to the brain, leading to a certain type of dementia (vascular dementia). A stroke that interrupts blood flow to the brain also can cause vascular dementia.