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MANAGEMENT OF HYPERTENSION IN ELDERLY: A CASE REPORT

OF FAMILY MEDICINE

AUTHORS:
Laurencia Violetta, XC064181070
Maydhista Anggraini Poetri, XC064181647
Telly Devi Oktaviani, XC064181036

SUPERVISOR:
Dr. dr. Suryani Tawali, MPH

DEPARTMENT OF COMMUNITY AND PREVENTIVE MEDICINE

FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY

NOVEMBER, 2019
MANAGEMENT OF HYPERTENSION IN ELDERLY: A CASE REPORT
OF FAMILY MEDICINE

Laurencia Violetta1*, Maydhista A. Poetri1*, Telly Devi Oktaviani1*, Suryani Tawali1*

1) Department of Community and Preventive Medicine

*Faculty of Medicine Hasanuddin University, Makassar, Indonesia

ABSTRACT

Hypertension is commonly found in primary health care and is the most common
cause of mortality due to cardiovascular disease and stroke. Management strategies for
hypertension include identification of risk factors and clinical problems with both patient
and family approach. This descriptive study was obtained through home visits, history
taking and physical examination, and identification of psychosocial and environmental
issues. Holistic diagnosis was assessed. This case describes a 62-year-old geriatric
female with hypertension. Internal risk factors obtained were unhealthy lifestyle, stress,
curative treatment pattern and poor knowledge about the disease. External risk factors
included lack of family support and knowledge to motivate patient to do routine check-up
and maintain her diet. Patient was given anti-hypertensive medication and education on
good eating and exercise habit, as well as the importance of treatment and check-up
compliance. Family is a major suppport system for the elderly in maintaining their health,
thus family support is needed to help patients control their blood pressure. Complex
clinical problems require a long time and collaboration between doctors and the patient's
family. Family doctor not only resolves the patient's clinical problems, but also seeks and
provides solutions to issues that affect the health of the patient and family.

Keywords: Hypertension, Elderly, Family Medicine

INTRODUCTION

Hypertension is a manifestation of hemodynamic disturbance which is defined as

an increase in systolic blood pressure ≥140 mmHg and diastolic
≥90mmHg. Uncontrolled hypertension will lead to organ damage and is a risk factor
involved in the process of cardiovascular disease. An increase of 20/10mmHg in blood
pressure will double the risk of cardiovascular disease (JNC 7, 2004). In general,
although patients often do not present with symptoms, hypertension is one of the
highest causes of death worldwide, thus often referred as to the "silent
killer". Hypertension causes as many as 45% and 51% of total deaths from
cardiovascular disease and stroke, respectively (WHO, 2013). There are 1.13 billion
people diagnosed with hypertension and 9.4 million people died from hypertension and
its complications worldwide (WHO, 2019).
Two-thirds of patients with hypertension live in developing countries. Data from
Infodatin (2014) showed there were 65 million indivuduals with hypertension in
Indonesia, in which 55.2% are above 55 years old. With increasing age, the incidence of
hypertension increases due to aging process, as well as lifestyle changes such as
excessive salt consumption, smoking, alcohol, lack of exercise and prolonged exposure
to stress.
Efforts in managing hypertension include early detection by primary care
workers in the community. The treatment principle should include control of blood
pressure as well as the risk factors associated (Kemenkes, 2013). Data from Riskesdas
(2013) showed that 32.3% patient do not regularly take medications, with the most
frequent reason is because patients already feel better (59.8%), irregular visits to health
centers (31.3%) and other reasons include a matter of cost, laziness or
boredom. Compliance with treatment is important because hypertension cannot be
cured and can only be controlled.

CASE DESCRIPTION

Mrs. N, a 62-year-old female, came to Mamajang public health center presenting

with headache for 2 weeks, which was on and off in frequency and felt especially at the
back of the head radiating to the nape. The headache disturbs her sleep and her daily
activities. In addition, patient also complained of dizziness and blurry vision. The patient
felt similar complaints 3 years ago, was diagnosed with hypertension and was given
antihypertensive medications. After completing her medications and feeling better,
patient would not go for a routine check-up and only visited when similar complaints
recur. She mentioned that her highest blood pressure reached 170/110mmHg.
She eats 3 times a day, where she admitted that she frequently consumes salty
food such as salted fish, fritters and instant noodles, and rarely consume fruits and
vegetables. Patient still does her daily activities washing customers’ clothes, cleaning
the house and rag picking. Patient seldom exercises, does not consume alcohol nor
smoke. She does not have history of other diseases. Her husband and parents passed
away due to illness of unknown causes. Her fifth daughter has hypertension.
Mrs. N lives with her two children, two in-laws and five grandchildren. She
constantly worries about being able to provide for the family. She mentioned that her
salary from washing clothes is usually not given on time. Patient’s treatment patterns are
curative, where she would take medications only when she feels sick. Similarly, her
family also would only seek treatment when they are not feeling well. The house she’s
living at is 6 by 5 in size, in the form of tenement. There was poor lighting and ventilation,
the means of disposal waste is substandard and litters are usually thrown carelessly.
Physical examination shows general conditions: mild illness; temperature: 36.5°C;
blood pressure: 150/90mmHg; pulse: 87x/minute; breath: 18x/minute; weight: 45kg;
height: 156cm; BMI: 19 (normal). Eyes shows haziness, ears and nose are within normal
limits. Cor, pulmo and abdomen regio are within normal limits. No signs of edema.
Neurological status is within normal limits. Investigations were not evaluated.
Figure 1 summarizes the interaction between different factors influencing the
patient's health state. In accordance with the concept of Mandala of Health, 1) personal
problems that the patient was experiencing are complaints of headaches that radiates to
the neck accompanied by dizziness and blurred vision. Sleeping problems and disrupted
daily activities often worsens the patient wellbeing. Patient expect her illness can be
cured and complaints does not recur; 2) The working diagnosis obtained was grade I
hypertension (ICD10-I10); 3) Internal risk aspect in this case was a geriatric patient with
unhealthy eating habits, often consumes salty, fried foods and instant noodles, seldom
consumes fruits and vegetables, and rarely exercises. Patient and family have curative
treatment patterns. Patient constantly worries about family’s living cost because her
work salaries are usually not given on time; 4) External risk aspects showed that the
patient lives with 9 other occupants in a small house, with poor cleanliness, ventilation
and lighting. Patient works as a laundress and rag picker to cover the family living
expenses; and 5) the functional scale of the patient was classified as degree 1 (one), ie.
patient is still able to carry out activities normally.
The treatment plan for this case was to control blood pressure with anti-
hypertensive drug Amlodipine 10mg. As for psychosocial problems, counseling was
given to the patient and her family about hypertension and its complications, as well as
lifestyle changes.

DISCUSSION

A home visit was carried out on November 6, 2019 where we explained the
purpose of the visit, followed by interview on the patient’s illness and obtain a thorough
history of the family. Based on the visit, we found a health problem of a geriatric female
who had repeatedly experienced symptoms of hypertension, had been diagnosed with
hypertension and received treatment for the last 3 years, but complaints still recurred
that it started to disrupt her sleep and daily activities. The clinical diagnosis of
hypertension was established based on the history obtained, in which she complained of
headaches that worsen especially during stress and that her sight starts to
blur. Hypertension is often dubbed as the silent killer as it often runs without symptoms,
and only appears when there are organs complications. Unspecified complaints such
as headaches, anxiety, blurred vision, dizziness, fatigue, palpitations and chest pain are
common to be found in people with hypertension (Yogiantoro, 2014). Blood pressure
obtained during the visit was 150/90mmHg, and according to The Seventh Report of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7), a diagnosis of grade I hypertension was established.
Our visit also showed that the patient had a lack of knowledge about the
disease she was suffering from, which was seen by the patient's curative medical
treatment pattern. Affordable health care facilities are available nearby, but patients and
families only seek treatment if there are complaints. In addition, she has poor knowledge
about preventive medicine, which was seen from her eating habit that is not in
accordance with doctor's recommendations. She often consumes foods high in salt and
saturated fat, rarely eat fruits and vegetables. She also does not exercises, but she
works as a laundress and rag picker every day. In terms of psychosocial aspects,
patients often feel stressed thinking of family living expenses, which is aggravated by
her work salary that is often not given on time.
The management in this case begins with blood pressure control which aims to
slow the progression of disease complications such as stroke, retinopathy, nephropathy
and cardiovascular disease. Non-medical intervention is the first-line therapy for
hypertension in the elderly and is very important because of the potential drug
interactions that can occur, as well as the problem of non-compliance with
treatment. A randomized controlled trial by Whelton (1998) showed that
dietary sodium restriction and weight loss result in greater improvement in the elderly
than younger patients. Education was given to the patient and family about DASH diet
(Dietary Approaches to Stop Hypertension), by avoiding salted fish, fried foods and
instant noodles due to their high salt and saturated fat content. Patient was advised to
eat diet rich in fruits and vegetables, and was advised to increase physical activity with a
minimum of 30 minutes per day (Nguyen, 2012).
According to guidelines by JNC- 8 (2014), medical therapy must be given to
patients over 60 years of age with a target blood pressure below 150/90mmHg. In this
patient, the pharmacological agent given was Amlodipine, a calcium channel blocker,
with a dose of 10 mg given once a day at night. The choice of this anti-hypertensive
drug was based on the patient's clinical condition, the relatively affordable price, easy to
obtain at the nearest health facilities and endurable side effects.
The patient is an elderly, and the risk of developing hypertension is greater with
increasing age due to arterial stiffness from aging process (Lionakis, 2012). Indonesia
has the top five largest number of elderlies in the world, and this increasing population
requires a strategic health care plan for the elderly. The government has launched the
development of integrated services for the elderly by establishing integrated outpatient
care and acute geriatric treatment centers, as well as conducting programs such as
elderly nutrition, psycho-geriatric services and dementia care, prevention of chronic
diseases and counseling (Setiati, 2013). However, the quality of life of the elderly is
influenced by many factors, and family support is one of the most important amongst.
Suardana (2010) reported that there are still a large proportion (> 50%) of elderly
patients with hypertension who still do not get enough family support. This may be
caused by poor family understanding of the illnesses suffered by the patients, so they
are not aware of changes or symptoms experienced by the elderly, as well as lack of
supervision in diet, lifestyle, and compliance in taking medication.
Management of psychosocial aspects in this case was given in the form of
counseling for the patient and the family. Elderly, who have decreased function and
have chronic diseases such as hypertension, constantly needs support and help from
others. The family is the main support system for the elderly in maintaining their health
(Wulandhani, 2014). The role of the family in elderly care includes information support
that is knowing the disease suffered by the elderly, providing knowledge about the
disease to the patient and reminding them to check blood pressure regularly, as well as
emotional support that is changing the mindset of curative treatment, caring to provide
free time to assist elderly to health centers for routine control, regulating their diet and
reminding the elderly to take medication regularly. In addition, a theory by Smeltzer and
Bare (2002) suggested that patients who are stressed or anxious will not be able to get
proper rest. Emotional stress result in vasoconstriction, increased arterial pressure and
increased heart rate, thus causing an increase in blood pressure and aggravate patient
complaints. Therefore, it is also important to counsel families to provide attention and
allows discussion with patients about what causes their stress.

CONCLUSION

The diagnosis of grade I hypertension in elderly female patient was obtained

through history taking which was complaints of headache, dizziness and blurred vision,
as well as physical examination showing an increase in blood pressure above
140/90mmHg. Management in cases of hypertension requires a patient and family
oriented approach. In patients, antihypertensive medication and education about diet
and exercise, as well as the importance of compliance in treatment and routine control
were given. The family is the main support system for the elderly in maintaining their
health, thus the availability of families is especially important to provide
support in increasing the willingness of the elderly with hypertension to routinely check
blood pressure and adhere to treatment to allow maximum benefit from the treatment.
Figure 1. Mandala of Health
 REFERENCE

1. Infodatin (2014). Pusat Data dan Informasi: Hipertensi. Kementerian Kesehatan,

Jakarta.
2. JNC 7 (2003). The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure. JAMA, United States.
3. JNC 8 (2014). The Eighth Report of the Joint National Committee: Evidence-Based
Guideline for the Management of High Blood Pressure in Adults. JAMA, United
States.
4. Kemenkes RI (2013). Pedoman teknis penemuan dan tatalaksana penyakit
hipertensi. Direktorat Pengendalian Penyakit Tidak Menular, Jakarta.
5. Lionakis N, et al (2012). Hypertension in the elderly. World J Cardiol, 4(5):135-147.
6. Nguyen QT, et al (2012). Managing Hypertension in the Elderly: A Common Chronic
Disease with Increasing Age. Am Health Drug Benefits. 5(3):146-153, United States.
7. Riskesdas (2013). Riset Kesehatan Dasar. Kementerian Kesehatan RI, Jakarta.
8. Setiati S (2013). Geriatric Medicine, Sarkopenia, Frailty dan Kualitas Hidup Pasien
Usia Lanjut. Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas
Indonesia, Jakarta.
9. Smeltzer & Bare (2002). Buku Ajar Keperawatan Medikal Bedah. Edisi 8, Jakarta.
10. Suardana WI, et al (2010). Dukungan keluarga dan kualitas hidup lansia hipertesi.
Poltekkes, Denpasar.
11. Whelton PK, et al (1998). Sodium reduction and weight loss in the treatment of
hypertension in older persons: a randomized controlled trial of nonpharmacologic
interventions in the elderly (TONE). TONE Collaborative Research Group, JAMA,
US.
12. WHO, (2013). A global brief on hypertension silent killer. World Health Organization.
13. WHO (2019). Fact Sheets: Hypertension. www.who.int. World Health Organization.
14. Wulandani SA, et al (2014). Hubungan dukungan keluarga dengan motivasi lansia
hipertensi dalam memeriksakan tekanan darahnya. JOM PSIK. Vol.1 No.2. Riau.
15. Yogiantoro M, (2014). Pendekatan Klinis Hipertensi. Dalam: Buku Ajar Ilmu Penyakit
Dalam. Edisi ke-6. Departemen Ilmu Penyakin Dalam FKUI, Jakarta.