Journal of Human Hypertension (1998) 12, 117121 1998 Stockton Press. All rights reserved 0950-9240/98 $12.

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ORIGINAL ARTICLE

Hypertension in nursing home patients

JS Trilling, J Froom, IH Gomolin, S-s Yeh, RC Grimson and S Nevin
State University of New York, Stony Brook, NY, USA

There have been few studies of hypertension in nursing home patients. To assess the prevalence, demographic characteristics, comorbidity and drug therapy in hypertensive nursing home patients compared with those who are normotensive, we reviewed all medical charts of patients in three nursing home facilities. Of the 804 patients, 355 (44.2%) have hypertension. Calcium channel blockers were the most frequently prescribed anti-hypertensive (30.3%) and together with diuretics (28.4%) and ACE inhibitors (27.7%) account for more than 85%. Hypertensive patients take more cardiac, hypoglycaemic, and analgesic drugs (P = 0.001, 0.001, and 0.004, respectively) than those who are normotensive. Overall patients take an average of 8.68 medications daily. In hypertensive patients, the average number of comorbid conditions (excluding

hypertension) is 5.02 compared with 3.23 in normotensive patients. Hypertension is signicantly associated with diabetes, heart disease, cerebrovascular disease, neoplasms, endocrine disorders, gastrointestinal diseases, psychiatric disorders, dementia, other central nervous system diseases, skin problems, blood diseases and inversely with hip fracture. Blood pressure control (140/90 mm Hg) is achieved in 88.8%, is not related to age and is signicantly more frequent in males than females (91.8% vs 82.6% P = 0.025). The problem of hypertension in nursing home patients is complex and has received insufcient study. Since studies demonstrating benet from anti-hypertensive therapy in the elderly excluded the very elderly and those with signicant comorbid conditions, additional research is needed.

Keywords: hypertension; comorbidity; medications; nursing homes; aged

Introduction
For the 50 to 60 million Americans with hypertension, pharmacological therapy reduces risks of congestive heart failure, cardiovascular events, renal complications, and all cause mortality. Although anti-hypertensive drugs benet almost all groups,1 11 therapeutic gains are less certain for persons over age 80 years and those with signicant comorbidity for which additional medications are administered.12 There is also uncertainty about the extent of cardiovascular risks from uncontrolled hypertension in the very aged.12 Of the 1.5 million nursing home residents in the United States, almost 40% are aged 85 and older.13 Little is known about hypertension in nursing home patients. The prevalence of hypertension reported in the 1985 National Nursing Home Survey is only 14%,14 considerably lower than rates of 54.9% for non-institutionalised persons aged 6574 years,15 and 34% (males) and 50% (females) for those aged 85 years and older.16 To assess the prevalence of hypertension and better dene the demographic characteristics, comorbidity and drug therapy in nursing home patients, we reviewed the medical charts of all residents of three nursing homes.
Correspondence: Dr Jeffrey S Trilling, Associate Professor of Clinical Family Medicine, Department of Family Medicine HSC, State University of New York at Stony Brook, Stony Brook New York 11794, USA Received 28 May 1997; revised 2 September 1997; accepted 23 September 1997

Materials and methods

The combined patient population of the Long Island State Veterans Home, Gurwin Jewish Geriatric Center and the Veterans Administration Medical Center Nursing Home, all located on Long Island, NY, USA, and afliated with the State University of New York at Stony Brook, at the time of the study was 804. Medical charts were reviewed for demographic data, medical conditions, the three most recently recorded blood pressures (BP), activities of daily living assessment, anti-hypertensives, and other medications. Medical disorders were classied using an abbreviated version of the ICD-9-CM,17 used to report morbidity in the 1985 National Nursing Home Survey.14 Hypertension was present if that diagnosis appeared on the problem list, or if the average of the last three recorded BPs 140 mm Hg systolic or 90 mm Hg diastolic. We dened BP control as an average of the last three recorded BPs 140 mm Hg systolic and 90 mm Hg diastolic. Anti-hypertensive drugs were classied as calcium channel blockers, alpha-blockers, ACE inhibitors, beta-blockers, peripheral vasodilators, and thiazides. Drugs other than anti-hypertensives were classied as analgesics, cardiac, hypoglycaemic, gastrointestinal, antibiotics, laxatives, psychiatricneurological, laxative, topical, vitamin-mineral, drug given as needed (PRN), and others. Enemas and dietary supplements were excluded. Activities of daily living were classied on a scale of (1) to (5) with (5) the poorest function. Data comparisons were made using the Pearson 2 statistic.

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Table 1 Age and gender of patient population in % (n =804) % of Population Age 65 6574 7584 85+ Gender Male Female Total Hypertension (n = 355) Normotension (n = 449)

Table 3 % of patients taking medications other than anti-hypertensives (n = 804) Medication group 1 No. of Medications 2 7.1 8.8 1.0 7.2 2.2 31.3 12.7 18.3 15.2 14.2 13.6 3 or more 0.6 1.8 0.1 0.8 0.2 19.7 5.6 16.2 7.3 6.2 6.6

8.0 25.0 36.2 30.8 69.4 30.8

35.9 48.8 45.4 41.1 44.6 43.1 44.2

64.1 51.1 54.6 58.9 55.4 56.9 55.8

Analgesics Cardiac Diabetic Gastrointestinal Antibiotics Laxatives Neuro-psychiatric Topical Vitamins minerals PRN Other

38.2 22.9 12.3 26.4 12.4 47.0 32.5 28.9 32.8 36.4 32.6

Results
Hypertension Age and gender distributions of hypertensive patients compared with those not hypertensive show no signicant differences (Table 1). Almost a third (30.8%) are aged 85 years or older. The percentage of males (69.4%) in the population studied differs from the national gure of 27%,18 because two of the three nursing homes are for military veterans. Medications Of the 355 patients with a diagnosis of hypertension, 86 (24.2%) are not taking anti-hypertensive medications. The distribution of antihypertensives among the 264 patients treated for hypertension is shown in Table 2. Calcium channel blockers, diuretics and ACE inhibitors account for more than 85%. Over 90% receive either one (58.7%) or two (32.7%) medications. There are no statistically signicant differences in achieving BP control between the different medication groups. The distribution of medications by drug category for all patients appears in Table 3. Virtually all patients receive laxatives and all medication groups were well represented. A comparison of the numbers of daily medications between hypertensive and normotensive patients is detailed in Table 4. NursTable 2 Distribution of anti-hypertensive medications in % (n = 264) % of Patients Anti-hypertensive medications Calciun channel blockers Diuretics ACE inhibitors Beta-blockers Alpha-blockers No. of anti-hypertensives 1 2 3 4 5 Missing data ve patients Table 4 % of patients taking two or more medications including anti-hypertensives No. of medications Hypertensive (n = 355) 1.1 3.1 4.2 9.0 12.7 12.4 16.6 12.1 7.0 20.8 9.42 3.68 0.20 8.68 s.d. 3.63 Normotensive (n = 449) 2.0 5.1 5.6 9.8 10.9 13.8 13.8 12.7 8.5 16.5 8.0 3.49 0.17 s.e. 0.13

2 3 4 5 6 7 8 9 10 11+ Mean/Pt. s.d. s.e. Mean medications/patient All patients

s.d. = standard deviation; s.e. = standard error.

ing home patients take a mean of 8.68 medications daily, but hypertensive patients take more than normotensives (9.42 vs 8.0, P 0.001. Hypertensive patients take more cardiac, hypoglycaemic, and analgesic drugs (P = 0.001, 0.001, and 0.004, respectively) compared with those who are normotensive. Comorbidity Comorbidity is a frequent nding among nursing home patients, but we found signicant differences between hypertensive and normotensive patients in some disease groups (Table 5). In hypertensive patients, the average number of comorbid conditions (excluding hypertension) is 5.02 compared with 3.23 in normotensive patients. An increased prevalence of hypertension is expected in patients with diabetes, renal and vascular diseases, but we also found signicant associations with neoplasms, endocrine disorders, gastrointestinal diseases, psychiatric disorders, dementia, other central nervous system diseases, skin problems, and blood diseases. We noted an inverse relationship with hip fracture. Activities of daily living scores are similar in

30.3 28.4 27.7 8.3 5.3 58.7 32.7 6.7 1.5 0.4

Hypertension in nursing home patients JS Trilling et al

Table 5 Comorbidity rates in nursing home patients in % (n = 804) Selected diseases and categoreis ICD-9-CM No. of patients Hypertension (n = 355) 25.1 10.4 37.5 53.8 24.5 4.5 23.9 8.2 33.5 40.0 21.7 25.6 23.7 25.6 12.4 3.7 5.02 2.96 0.26 Normotension (n = 449) 7.6 5.8 16.9 27.4 13.8 1.8 14.0 4.5 19.2 32.2 10.7 12.2 16.0 14.9 7.8 7.1 3.82 3.82 0.23 P values

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Diabetes Other endocrine disease Cerebrovascular disease Heart disease Renal disease Psychoses Depression Other mental disease CNS problems Dementia Arthritis Other skin disease Gastrointestinal disease Blood disease Neoplasms Hip Fracture Mean all Categories/Patient s.d. s.e

123 63 209 314 149 24 148 49 205 287 125 146 156 158 79 45

.001 0.015 .001 .001 .001 0.024 .001 0.029 .001 0.024 .001 .001 0.007 .001 0.030 0.034

CNS = central nervous system; s.d. = standard deviation; s.e. = standard error.

hypertensive compared with normotensive patients, except for mobility that is signicantly worse in the hypertensive group (P = 0.003). Analgesics are more frequently prescribed for patients with heart disease, hypertension, cerebrovascular diseases, and other mental disease. Blood pressure control Among the 355 patients with a diagnosis of hypertension, 316 (88.8%) have BPs 140/90 mm Hg. Control of BP in patients taking anti-hypertensives (n = 269) is 88.8% and is not related to age but is signicantly more frequent in males than females (91.8% vs 82.6% P = 0.025). BP control is less frequent in patients with three comorbid conditions; dementia (80.2% vs 94.5%, P = 0.001), osteoporosis (76.7% vs 90.4%, P = 0.025), and other central nervous system conditions (81.3% vs 93.1%, P = 0.003). Other comorbid conditions such as diabetes, and vascular diseases appear not to affect control of BP. Although BP control is more frequent in patients taking a single anti-hypertensive as compared with those taking two or more, the differences are not signicant.

Discussion
In our study more than half of the hypertensive patients are taking a single anti-hypertensive drug, similar to studies reported in younger patients.1921 Until recently, diuretics and beta-blockers were the only drugs with demonstrated efcacy for prevention of complications in clinical trials of elderly hypetensive persons.811 The latest report from the Systolic Hypertension in the Elderly Program (SHEP) conrms the effectiveness of diuretics supplemented by atenolol or reserpine in both diabetic and non-diabetic elderly patients with isolated systolic hypertension,22 but diuretic use in elderly hypertensives has been declining.23 Recent studies

indicate that calcium channel blockers may be a suitable alternative.2426 Calcium channel blockers are the most frequently prescribed anti-hypertensives in our patient population but increased risks of myocardial infarction and other vascular events, gastrointestinal hemorrhage, and cancer associated with use of these medications have been reported.2732 A review of their risks by the Ad Hoc Subcommittee of the Liaison Committee of the World Health Organization and the International Society of Hypertension, however, concludes, The available evidence does not prove the existence of either benecial or harmful effects of calcium antagonists on major CHD events, including fatal or non-fatal myocardial infarctions and other deaths from CHD.33 They reach similar conclusions for effects on bleeding and cancer. We found a signicantly higher use of analgesics in our hypertensive patients compared with those not hypertensive. The association of hypertension in the elderly with non-steroidal anti-inammatory drugs (NSAID) as well as increases in BP in young persons taking these drugs have been reported.3437 Nursing home patients in our sample take an average of 8.6 medications daily, similar to the 7.2 to 8.1 reported by Avorn and Gurwitz.38 The large number of drugs used in nursing home patients, both hypertensive and not, suggests the need for careful monitoring and frequent re-evaluation of therapy.3942 Data on morbidity in nursing home patients are few. The 44.2% prevalence of hypertension in our study is considerably higher than rates reported in the 1985 National Nursing Home Survey,14 but equivalent to those reported for non-institutionalised persons and to a report from other nursing homes in Texas. In that cross-sectional survey of 617 patients in 17 nursing homes, rates of several chronic diseases are similar to those in our patients. We found 44% of our patients hypertensive compared with 40% of theirs. Comparable gures for other chronic problems are 17% vs 20% for depression, 26% vs

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30% for cerebrovascular disease, 39% vs 32% for ischaemic heart disease, and 20% for anaemia in both studies. There are larger differences for diabetes 15% vs 27% and arthritis 15% vs 36%.43 The differences in the male/female ratios and methods of data extraction between the two populations may account for differences in some disease rates. Our 36% rate of dementia compares with 43% reported in the National Medical Expenditure Survey.18 The increased prevalence of cerebrovascular disease, heart disease, and renal disease in association with hypertension might be expected because those are its complications. Endocrine disorders can be a cause of hypertension. We were unable to nd reports of an increased prevalence of hypertension associated with mental disorders, gastrointestinal disorders, neoplasms, blood disorders, arthritis and skin disease. The inverse relationship with hip fracture might be explained by the decreased urinary excretion of calcium resulting from administration of diuretics. Our data, however, are cross-sectional, and involve relatively small numbers of patients. These associations may be spurious, but merit analyses from larger patient data sets and longitudinal studies. Diabetes might result from anti-hypertensive medications or alternately hypertension could result from the increased cardiovascular risks in diabetic patients. Our data are insufcient to determine which mechanism is operative. In contrast to the US population in which 65% are aware that they have hypertension, 49% are receiving anti-hypertensive medication and 22% have their BP controlled,15 control of hypertensive nursing home patients BP is excellent. Good control should be expected because BPs are routinely taken at least monthly and anti-hypertensive medications are administered by nurses assuring compliance. The relationship between BP control and dementia, and central nervous system conditions, however, lack adequate explanations. The poorer BP control in women might explain the similar effect in patients with osteoporosis. Our data in hypertensive nursing home patients demonstrate the presence of multiple comorbid conditions requiring several medications. Clearly, therapeutic decisions for these patients are complex and have received insufcient study. Since studies demonstrating benet from anti-hypertensive therapy in the elderly excluded patients with signicant comorbid conditions and the very elderly, 811 additional research is needed.

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