Prevalence, Awareness, Treatment and Control of Hypertension among the Elderly in Canada: A Systematic Review

Background

Hypertension (HTN) is a major cause of the majority of cardiovascular diseases and that elderly people in Canada are exposed to. According to Benetos et al (2019), there is a rising prevalence rate of arterial hypertension across the world with severe cases being recorded with systolic hypertension. Currently, there is a high morbidity and mortality rate among the elderly in Canada today. Hypertension has increased the number of deaths among people above 50 years old due to certain factors such as unhealthy living, a lack of physical activity, and other diseases such as obesity. There is a high expectation the number of people living with hypertension will rise to over 1.5 billion people by the time we get to the year 2025.

Canada, for many years, had left the management and treatment of hypertension patients to family specialists and physicians. There has not been controlled surveillance of hypertension management which has resulted in the high mortality and morbidity rate we experience today (Schiffrin et al., 2016). There needs to be significant development of policies to ensure that there is a definition of procedures. Additionally, to prevent hypertension in the country, proper population-based strategies need to be incorporated into the hypertension management system. The strategies include; access to healthcare, optimization of management and treatment of hypertension, and accuracy in measuring blood pressure.

Adopting these strategies in Canada will ensure that cases of morbidity and mortality among elderly people reduce. The strategies will also ensure that proper medical intervention for elderly people is adopted to reduce the number of deaths. While looking into these factors, we need to assess the prevalence, awareness, treatment, and control of hypertension cases among the elderly in Canada so that we can control hypertension in this population.

 

Objectives

The review aims to analyze the prevalence, awareness, treatment, and control of hypertension among the elderly in Canada. The review will evaluate hypertension under the following scope;

1. Check the prevalence and awareness levels on issues related to hypertension among the elderly in Canada.
2. Evaluate control and treatment methods currently under use within the country.

The essential research questions for the review will include;

1. What is the prevalence rate of hypertension in Canada?
2. Are the elderly aware of their condition?
3. What treatment and control methods do the elderly receive to treat hypertension?

Methods

Definitions

1. For this study, hypertension was defined as the systolic blood pressure (SBP) ≥ 140 and the diastolic blood pressure (DBP) ≥ 90 mmHg. Additionally, hypertension was described as any reported use of medication meant to treat any hypertensive condition.
2. An elderly individual was defined as any person older than 50 years old.
3. In defining hypertension treatment rate, the review looked into the proportion of individuals with hypertension awareness and was under the medication of anti-hypertensive medication.
4. The rate of hypertension awareness was defined as the number of people who were aware that they had been diagnosed with hypertension and were under specified medication or treatment.
5. For hypertension control, the review defined it as the number of people placed under hypertension treatment and management. The mode of management or control defined as either pharmacological intervention, modification of lifestyle, and/or both methods of intervention. The control rate had SBP ≥ 140 mmHG and DBP ≥ 90 mmHG.
6. The occupational level of participants in the review was categorized into three; low, medium, and high. At a low level, the participants were not required to have technical skills or any type of training. At this level, manual workers were highly recommended. At the medium level, the participants were required to either have a university degree, technical skills, and technical training. The level was convenient for salesmen and taxi drivers. Finally, the high level required individuals with high technical skills and training. Occupation at the high level included health professionals and accounting experts.
7. The body mass index of participants was computed by taking the weight of a participant and dividing it with their heightened that was recorded in meters. The body mass index (BMI) for the body habitus was categorized underweight (BMI < 18.5), normal (BMI = 18.5-24.9), overweight (BMI = 25.0-29.9), and obese (BMI ≥ 30).

 

 

Search Strategy

This research engaged in a review of the existing literature on the topic. Articles used were those that touched on prevalence first which meant to provide critical information on the distribution of hypertension in Canada. Critical information was obtained from Schiffrin et al., (2016) on the state of hypertension in the country. The article gave information on the changes that have taken place over time and future expectation while dealing with hypertension.

More essential information was obtained from Benetos et al., (2019) on the essential practices that are employed to take care of old and frail patients in the country. The search for articles to be included in the review was tailored by following the needs of the review. Articles that discussed issues on hypertension that covered elderly people were included in the review because they contained valuable information necessary for the review. Most of the articles we accessed were from online sources such as JSTOR and NCBI which were very helpful with the information the articles provided. The articles selected had specifically deal with hypertension among the elderly people since for other ages, different intervention methods collided with the criteria we required. For every search on the internet, every selected article had to have ‘elderly people’ as the keywords.

Selection Criteria

While selecting appropriate articles, there were several guidelines we used to either include an article or exclude it.

Inclusion Criteria

• The articles selected were published between 2015 and 2021.
• The studies chosen had to be conducted using English as the main language.
• For peer and non-peer review articles, the articles selected contained essential information on the hypertension situation in the country. The articles also gave historical data on how hypertension has been handled in the country over time. Additionally, the articles contained more information on the intervention and control methods for the elderly which included the medication provided. Finally, the articles selected contained critical information on home care provided to the elderly in terms of prevention and management of hypertension.
• The review concentrated on articles that had a similar situation to Canada with regards to the hypertension situation.
• The studies from the articles chosen were conducted within the country.
• The studies chosen by the review were either ongoing or had been completed.

Exclusion Criteria

• Inconclusive research that did not have intervention methods or key details related to hypertension.
• Articles that did not contain conclusive data on hypertension and only gave hypothetical information.
• Research articles that gave general information about hypertension were also not included.
• Articles that were not specific on the sample size and used broad-spectrum as the sample were also excluded.

There was also information from different inconclusive articles that were used. Some articles contained valuable information about the state of hypertension in Canada but lacked conclusive data that would be essential to this review on hypertension. The essential information from the articles was used however they were not employed on sections where statistical data was needed. In cases where there were articles with similar data, the article with the most valuable information was selected because it gave deeper details on issues related to the subject.

Quality appraisal/Risk of bias in included studies

The review did not utilize a bias or risk assessment for all the articles that met the inclusion criteria. It was challenging to comment on the bias and risk of the articles because the information contained in the articles was very helpful to the review. At the stage of risk evidence assessment, a full bias and risk analysis will be carried out on articles with information that can affect the validity of the review. The articles that do not meet the criteria for the review will be eliminated and their findings not included in the review. The tool to be utilized for quality assessment has not been selected yet. However, a series of tools may be selected to undertake the quality assessment. They include; Cochrane manual, GRADE working group, and JAMAevidence. While assessing on an observational basis, the term quality was employed to show that the articles were chosen based on the appropriate methodology the authors had at hand.

Data Extraction

While conducting searches for essential data, data was extracted from different websites. Articles from the internet were analyzed to ensure they met the inclusion criteria for the required database. Each article had a review done independently to ensure that each met the selection criteria. Additionally, each article was checked once which helped save enough time to compile essential data meant for the review. The articles were also checked for consistency to ensure that the information in the articles conformed to the required database. Also, consistency involved checking the articles for essential data that would give productive information that would review substantially. Consequently, all the data required from the articles were extracted and recorded on a data form. Whenever there was an issue related to consistency, the reviewers discussed to decide whether a particular article would be included or discarded. While extracting data, the reviewers looked at different aspects contained in the articles such as the study design, interventions cited by the study, and the outcomes each study had. Data extracted was counterchecked to ensure that all the essential details required for the review were included in the data extraction form.

Data Management

Deduplication of abstracts from the database was done by uploading these abstracts to the reference management software EndNote. After counter-checking the abstracts, the data were further checked for inclusion criteria to ensure that all articles utilized in the review met the required threshold. All the numerical data collected from all the articles were kept in Excel documents for easier interpretation when including the data in the review. For identification purposes, all the excluded data was recorded at this stage so that when any information was required while compiling the review it would be easily accessed. After identifying the necessary abstracts, the reviewers accessed the necessary full-text papers that contained necessary information on hypertension in the country. The full papers had to meet the inclusion criteria to qualify for consideration. Additionally, the full-text papers had to contain credible and updated information about hypertension in the country. All the studies that passed the inclusion criteria were placed in the reference management software EndNote.

Reporting

The group created a proper interactive online program that people interested in the work would easily interact with. The group preferred the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting so that the information through the review would have good clarity and adequate evidence covering the matter. The team also employed the services of an information technology expert who would ensure that the online program created was user-friendly. The expert would also ensure that all online programs we utilized ran smoothly to avoid any loss of information or inadequate corruption of essential data required for the review. Finally, the expert ensured that all information saved in the database was easily accessible for all reviewers whenever they required it.

Limitations of the Study

• While conducting the review, we found out the most of the articles employed the cross-sectional method for their study. Therefore, defining hypertension was based on measurements and values received from a single encounter in each study. For proper results, hypertension measurements should have been conducted on repeated measurements to develop a concrete definition.
• In most studies, patients considered to have hypertension had episodes of elevated blood pressure. Classifying such patients as having high blood pressure resulted in an overestimation in the number of people recorded to have hypertension. The issue also resulted in a high prevalence rate recorded in the database.
• Conducting such reviews requires a significant amount of revenue to compile. The review required software such as EndNote and the use of an information technology expert. Utilizing such resources requires a significant investment to be put into coming up with the review. Additionally, revenues to acquire information especially from certain journal cite so that information in the review is authentic.
• Many of the organizations that conduct these studies have a bias while reporting their findings. In the majority of cases, organizations only concentrate on the positives of the studies and do not share the failures and shortcomings the studies had. Additionally, these organizations are never ready to share their failures and shortcomings because they believe it might tarnish the good reporting done.
• Many studies were also not specific to the risk factors that lead to hypertension. Factors such as salt consumption, habits related to smoking, physical activity, and hypoglycemia were not covered which are crucial contributors to the development of hypertension.
• The review would only include documents and articles sourced from the internet. We did not have access to documents not on online platforms which reduced the essential information we would have added into the review. All the online sources had similar information which reduced the broadness of information we added into the review.
• Different terms had different definitions in different studies. The definition of a term was based on the amount of research done on different studies which meant that the articles that met the selection criteria had a different definition.

Findings

According to Campbell et al., (2015) they selected Canada as their main sources of information on hypertension. In their study, 72% of participants in Canada met the criteria for people with hypertension. The factors to qualify in the study were people with a BP of ≥140 mmHg or who were under medication meant to lower blood pressure. The study analyzed the factors associated with the treatment of hypertension among the elderly in Canada. The study gave different results such as the characteristics of the population with hypertension through treatment and control of blood pressure, the factors that are related to untreated hypertension, and the factors associated with uncontrolled hypertension.

Garies et al., (2019) conducted a study on the prevalence in hypertension treatment and the targets of blood pressure in Canadian society. They found out that of among the people included in the study with a sample size of 594492 people, 24.2% which represented 144348 people suffered from hypertension. The mean age of the participants found to have hypertension was 65.5 years with men being 45.6% of the positive cases. They concluded that the highest percentage of people in Canada with hypertension were the elderly, with younger people found to only have varied changes in their blood pressure. They concluded that the number of elderly people with hypertension from their sample side was 71.8% with 12.3% of them recording serious cases of hypertension.

Harris et al., (2016) studied the prevalence, awareness, treatment, and control of hypertension among the elderly in Canada. They discovered that the age and gender in the population determined the levels of hypertension among the population. In their analysis, there was an increase in prevalence from 60.1% to 65.2% between 2001 and 2010. During the same period, they discovered that the awareness, treatment, and control increased from 69.8% to 74.5%, 50.3% to 63.7%, and 15.3% to 30.3% respectively. The significant increase resulted from increased efforts to control hypertension during the period of the study. The increasing numbers showed a positive response to awareness, treatment, and control.

Xie et al., (2016) discussed the effect that extreme lowering of blood pressure had on the cardiovascular and renal systems among patients in Canada. Their study had 44989 participants of whom 2496 had issues with their cardiovascular system. They found out that patients exposed to extreme lowering of their blood pressure using different interventions reduced the risk of exposure to cardiovascular and renal system failures. About 1.2% of patients in the study experienced severe effects of the extreme lowering of blood pressure. However, over 90% of the participants registered positive results. The study was beneficial to patients with cardiovascular issues because their exposure to hypertension was highly reduced. Additionally, they registered positive results in the subsequent cardiology tests that were conducted. Acar et al., (2015) discussed the relationship between hypertension and body balance among the population in Canada. In their findings, they stated that people with hypertension had higher imbalance values compared to people without hypertension. The participants selected had the same values of weight and height.

Table 1.1 Clinical characteristics

	HT Group	Non-HT Group
	Mean ± SD	Mean ± SD
Age (years)	80.5 ± 2.8	79.8 ± 3.8
Height (cm)	159.6 ± 9.3	158.7 ± 11.0
Body weight (kg)	71.7 ± 12.1	71.0 ± 14.8
BMI (kg/m2)	28.7 ± 10.1	29.6 ± 9.2
SBP (mmHg)	135.0 ± 21.0	148 ± 11.2
DBP (mmHg)	84.0 ± 18.0	85.0± 13.0

HT and Non- HT: hypertensive and non-hypertensive, SD: standard deviation, BMI: body mass index, SBP and DBP: systolic and diastolic blood pressures

 

Table 1.2 Balance Scores

	HT Group mean ± SD	Non-HT Group mean± SD
Eyes open firm surface (˚/s)	0.3 ± 0.1	0.2 ± 0.1
Eyes closed firm surface (˚/s)	0.8 ± 1.3	0.4 ± 0.2
Eyes open unstable surface (˚/s)	1.2 ± 1.3	1.2 ± 0.5
Eyes closed unstable surface (˚/s)	4.5 ± 1.9	3.5 ± 1.7

HT: hypertensive, ˚/s: degree/second

 

Hennessy et al., (2015) discussed the awareness, treatment, and control of hypertension and assessment quality among the elderly in Canada. In their findings, they discovered that elderly females were more aware of their condition as compared to men. They also found out that most of the participants in their study had a history of smoking and a lack of physical activity. These factors were the only issues among elderly Canadians that were checked whenever a patient was receiving care for hypertension. The study also discovered that elderly Canadians that had medical insurance were more likely to be aware of their hypertensive condition. They concluded that most people in the country were more exposed to hypertension due to the smoking and inactivity history in over 60% of the participants.

Milot et al., (2015) studied the unreliability of home pressure measurements that affect the intervention of patients with hypertension in Canada. They discovered that there was a 30% increase in prevalence due to poor measurements at home. From the total patients they had in their study, 54.7% of the total patients were aware of their hypertensive condition. There was however a lower percentage after intervention where 40.3% of the patients were aware of their hypertensive condition. There was a significant increase in each rate which represented a rise in the management and control of hypertension in the country. Education was a contributing factor to the rise in percentage because people in Canada were more aware of their health.

Muli et al., (2020) discussed the prevalence, awareness, control, and treatment among elderly people in Canada. They found out that the prevalence rate for people with a blood pressure of ≥ 140mmHg was 73.8 % in men and 73.5% in women. Among the patients with hypertension, the study registered that 80.2% were aware of their condition while 74.4% were under hypertension medication. They also discovered that people who had hypertension were more likely to be obese, have diabetes, and were advanced on age. They also stated that individuals who were under three hypertensive drugs were more likely to control their condition compared to patients under one type of medication.

Padwal et al., (2016) discussed the prevalence, control, and treatment among the elderly in Canada. The study included 612 elderly participants who were above 60 years. From the study, the researchers deduced that the prevalence rate of arterial hypertension stood at 74.9% with 78.6% of the participants being men. The treatment rate stood at 72.6%. High treatment rates were recorded among participants with a history of smoking. The rate of hypertension control stood at 50.8%. Butt and Harvey (2016) conducted a study to determine the risks and benefits associated with antihypertensive medication among the elderly in Canada. They concluded that treating high blood pressure with antihypertensive drugs among the elderly reduced different cardiovascular events such as stroke, and heart diseases. They had a sample size of 1620 hypertensive patients above 80 years. They also noted that continued use of antihypertensive medication helped the patients to control different issues such as regular sickness due to hypertension. There was a 70% success rate in their study and only a minimal 12% registered issues with antihypertensive medication.

In their study, Leung et al., (2019) looked into the control, treatment, prevalence, and awareness of hypertension among women in Canada. They deduced that there was a 49.7% prevalence rate among the participants who were fully treated. They also discovered that there was a link between ineffective treatment with obesity and heart diseases. From their study, a minimum of 24.9% of the participants was in control of their hypertension condition. The study done by Gupta et al., (2020), looked into the control, treatment, prevalence, and awareness of hypertension among Canadian rural dwellers. From their 194 hypertensive patients, they discovered that 58.8% knew about their hypertensive status. From the total participants, 96.5% were placed under hypertensive treatment while 24.5% had their blood pressure levels under control. Women who commanded 64.2% were more aware of their condition compared to 50.0% of men. Women also recorded a high 98.7% under treatment compared to 91.9% in men.

Williams (2018) discussed the control, treatment, prevalence, and awareness of hypertension among elderly people in Canada. He deduced that the prevalence rate among the participants stood at 63.7%. The participants with hypertension recorded 54.5% who were aware of their condition. A further 58.9% were under antihypertensive medication while 51.6% were under medication. Gee et al., (2016) conducted a study to determine the factors associated with a lack of control, awareness, and treatment among adults in Canada. They found out that a higher percentage of adults were under hypertensive medication due to a lack of proper education. From the study, women recorded higher cases compared to men in all outcomes.

Discussion

Results from Campbell et al., (2015) show that Canada made significant progress in controlling the hypertension rates. Various indicators such as lowering the blood pressure, using the medication, and controlling the blood pressure over a prolonged period had significant results in ensuring the state of hypertension was controlled. Though there was a significant improvement, a significant number of elderly people were not under medication. In the study by Garies et al., (2019), their results indicated that lowering the blood pressure to 130/80 mmHg would double the prevalence rate among the population with hypertension in Canada. By employing the policy, over 5 million Canadians would be classified as hypertensive.

The study was also consistent with other studies that stated that if the blood was moved from 140 mmHg to 130 mmHg then a majority of people within the country would be considered hypertensive. Therefore, the definition of the normal rates of blood pressure would affect the majority of the population. The research conducted by Harris et al., (2016) gave results that showed an increase in the prevalence rate among the participants aged 60 years and above. The rate moved from 48.4% in 1991 to 53% in 2009. The increasing prevalence indicated a rise in hypertension cases among the elderly. Additionally, due to high prevalence, there was an increase in people under medication over the period which improved the rate of treatment and control. Finally, the rate of awareness also grew with the growing prevalence because of increased education within the public.

The study by Xie et al., (2016) deduced that the intensive lowering of blood pressure had a greater effect on vascular protection compared to standard regimens. They also recorded patients who had severe hypertension benefited from an extreme lowering of their blood pressure which included patients with blood pressure below 140 mmHg. The study concluded that there were significant benefits to intensive lowering of blood pressure on the patients. Acar et al., (2015), aimed to assess whether hypertension affects the state of balance among hypertensive patients. From their results, the participants in the study did not have significant issues with their balance and posture. Different studies had recorded that people with hypertension suffer from dizziness which is a symptom of poor balance. They concluded that posture and balance were affected by a combination of different factors with included hypertension. Factors such as brain damage and ear damage were seen to be more dominant while dealing with poor balance and posture.

The research by Hennessy et al., (2015) concluded that hypertension is a serious public health issue when not properly resolved. Of all the participants included in the study, over half of them were not aware of their condition with regards to hypertension. The authors of the study also concluded that intensive healthcare intervention within the population was necessary so that there would be more control over hypertension. The results of the research also recommended that medical facilities are the best option for creating proper health intervention programs and quality assessments. The health facilities should facilitate home care programs that look to reduce the prevalence of hypertension within the population.

In their study, Milot et al., (2015) discovered that the prevalence rate among women was higher at 30.3% compared to the men. However, among adults in Canada, the representative population had a stable prevalence rate between which stood at between 31.8% and 30.3% with p > 0.05. The study also found out that the rate of awareness, treatment, and control increased from 40.7% -54.7%, 31.1% – 47.4%, and 8.1% – 28.7% with p < 0.00 after measurement quality was improved. The figures indicated that the population became more aware of their condition from 2003 to 2012. The values also show that more people became concerned about their general health and sought medical help to deal with their situations.

The study by Muli et al., (2020) showed that elderly people had a prevalence rate of 73.8%. The statistic translated to every three out of four elderly people above 60 years had hypertension. The study also recorded a higher prevalence rate in men than women from the data collected from the participants. The authors of the study gave caution that though there is a recorded increase in prevalence, clinical intervention might reduce the rates further. They also stated that high systolic blood pressure is not always linked with cardiovascular issues among the elderly. The research by Padwal et al., (2016) indicated that there was a high prevalence rate of 74.9% among the population compared to different studies carried out.

The elderly population recorded a higher number of people with hypertension compared to the population with a relatively lower age. Additionally, the rate of treatment was higher in women as compared to men. Consequently, access to treatment and awareness of hypertension was linked to the presence of information and higher education levels within the population. The high rate of prevalence was attributed to a lack of proper access to healthcare services within the population.

The study by Butt and Harvey (2016) concluded that when hypertension in the elderly is untreated, there is the risk of recording high mortality and morbidity rates. Hypertension in the elderly results in cardiovascular issues such as stroke and heart attack. Additionally, hypertension is related to issues with blood pressure that can complicate the health of an elderly person. The research recommends that physicians should take caution whenever administering medication to elderly people. Giving proper medication will ensure that elderly people control and treat hypertension before it gets to critical stages. Additionally, awareness is essential to ensure the elderly know about their health. In the research by Leung et al., (2019), the researchers concluded that the prevalence rate of hypertension in Canada remains very high among elderly people. The researchers recommended that medical professionals had a duty to identify the condition early so that it could be easily managed. Additionally, medical experts would ensure that the elderly had access to critical information so that they would know how to deal with the condition better. The researchers claim that putting these measures into place would ensure that the onset of high blood pressure would be noticed so that a visit to the doctor would be scheduled.

In the study by Gupta et al., (2020), the researchers concluded that the prevalence rate of hypertension among the elderly residing in rural areas was very high. Additionally, the elderly population was not aware of their health status which placed them at risk of developing severe symptoms of hypertension. The researchers also claimed that though a significant percentage of the participants were treated, the control measures were insignificant which placed the patients under further risk to develop severe hypertension. Williams (2018) found that there was a high prevalence rate of hypertension at 63.7% among the elderly people in Canada. From the total number of participants, 52.5% knew about their status while 56.9% were under antihypertensive medication. High awareness and treatment rates mean that the public is well educated and is taking action. According to Gee et al., (2017), some factors lead to a lack of control, awareness, and treatment among adults. The prevalence rate was very high which meant more people were diagnosed with hypertension. Additionally, though more patients were under medication, more needed to be done so that the population would become aware and take control of their health.

 

 

Conclusion

The Canadian health care system is mostly free and offers very easy access to services compared to other countries. It is an invaluable resource in a county that has a big portion of its population suffering from blood pressure. The literature reviewed in this systematic review shows a high prevalence of hypertension among the elderly in Canada. This prevalence presents with a low level of control, especially in the elderly male. The awareness is however high, with preventive efforts being undertaken by Canadian health initiatives, that take into consideration the risk factors in the elderly population. There should be more emphasis on secondary prevention needs to have better control in hypertension management, as well as the use of nonpharmacological management to avoid contraindication as people in advanced ages have a high risk of health complications that can be worsened by medications. There should be special efforts made in the prevention and management of hypertension in elderly women.

 

 

 

 

 

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