Introduction
Over the past years, there has been a high prevalence of hypertension among adults. Hypertension can be simply defined as the blood pressure pushing against the artery walls and therefore causing chronic health condition. According to Carroll, Dillon, Hughes, Ostchega and Yoon (2007) a survey carried out in 1999-2004 showed that about 67% of all adults in the US suffered from hypertension. However, the prevalence has increased over time and a survey conducted by the National Health and Nutrition Examination Survey from 2005 to 2008 indicated that the prevalence among adults of over 65 years is about 69.7% (Blair, Briss, Gillespie, Hong & Kuklina, 2011). It is more common in adults as compared to the younger ages because the blood vessels of the older people usually become less elastic as aging continues. This condition significantly increases vulnerability to end-stage renal disease as well as coronary heart disease. It also causes severe risks to congestion heart failure. Hypertension usually has no symptoms and therefore most people who suffer from it are not aware and they only realize after it has caused damages to the heart or brain. The National Heart, Lung and Blood Institute estimate that out of four adults, one has a continuously elevated high blood pressure. The situation is even worse for adults above 70 years whose prevalence rate is estimated as two out of three as being affected by the condition.
Etiology
Hypertension is always used to refer to a chronic medical condition of the cardiovascular system which raises the systemic arterial blood pressure. Hypertension is usually classified into two; primary and secondary hypertension with the most prevalent being primary hypertension. It causes 90-95% of hypertensive patients. Although the direct causes of this primary hypertension has not been identified, there are several factors which include stress, obesity, sodium sensitivity, sedentary lifestyle, alcohol intake, potassium deficiency, , visceral obesity as well as vitamin D deficiency (Chrousos, Kyrou, & Tsigos, 2006). In some cases, hypertension results from inherited genetic mutation. It may also be as a result of a family background that has a history of hypertension. The risk increases with increase in adult aging. On the other hand, the causes of secondary hypertension can be identified. It accounts for about 5-10% of all cases associated with high blood pressure (Babatsikou & Zavitsanou, 2010). Its treatment is therefore different from that of primary hypertension. This type occurs when there no balance in the pathophysiological mechanisms which regulate heart function as well as blood plasma volume. Some common causes include obesity, kidney disease, illegal drugs, cushing’s syndrome which results from excess production of cortisol hormone by adrenal glands as well as hyperthyroidism (Dodt, Sayk, Schutt, & Wellhöner, 2009).
Epidemiology
Previous studies show that the most affected groups are the African-Americans, low-socio-economic-status group as well as obese or overweight groups. According to Fernandez, Ogedegbe, Pineiro, Scales and Schoenthaler (2008) the prevalence rate among African Americans is about 33.5% while that of the Caucasians is about 28.9%. Babatsikou and Zavitsanou (2010) estimate the prevalence level of arterial hypertension among African Americans to be twice higher than the respective level among white Americans.
Effects of Hypertension on public health
Hypertension has a considerable effect on public health. Hypertension causes vulnerability to cardiovascular disease. The higher the blood pressure, the greater the risk for developing heart failure, kidney disease, stroke as well as heart attack. According to Babatsikou and Zavitsanou (2010) coronary heart disease has been the leading cause of mortality as well as morbidity among older adults. However, appropriate management of high blood pressure among hypertensive persons is still low since most people do not realize that they have the condition. According to Blair et al. (2011) Hypertension is responsible for one out of seven deaths that occur in the US and almost half of those deaths are related to cardiovascular disease. It costs so much to the US’s healthcare system. According to the American Heart Association estimated the total costs associated with hypertension to be over $93.5 billion annually (Blair, et al., 2011). Cardiovascular disease as well as stroke costs about 17% of the federal government’s total health expenditures per year. Considering that heart disease is ranked first while stroke is ranked third among the leading causes of death and disability in the US, it is essential that healthcare providers conduct early assessment of cardiovascular risk in patients and also implement evidence-based treatment strategies. It is therefore important for healthcare providers to advance their knowledge on early diagnose as well as appropriate treatment the diverse demographics. Health care practitioners need to adopt multiplicative approach in order to lower morbidity as well as mortality outcomes. According to Centers for Disease Control and Prevention (2011), in 2007 alone there were a total of 336,353 deaths in the US majorly attributed by hypertension and more than 46 million people visited health care facilities for hypertension in the same year.
Multiple strategies for achieving improved hypertension treatment include emphasis on dietary as well as lifestyle modifications. The challenges that the public face as a result of hypertension therefore include; how to improve affordable treatment opportunities which includes lifestyle modifications as well as pharmacological treatment; how to reduce prevalence of hypertension and cardiovascular disease among different ethnic as well as socio-economic groups; preventing rise of blood pressure levels with age and therefore reducing cardiovascular disease in older adults; how to improve control of high blood pressure and reduce cardiovascular risks (Fulmer & Zwicker, 2008); and finally how to reduce the current prevalence of hypertension among older adults. The use of Complementary and Alternative Medicine as a form of self-care is increasing in the US despite the fact that little is known about its use for treatment of hypertension (Arcury et al., 2006). It is important that patients with hypertension understand the use of Complementary and Alternative Medicine. Considering the lower number of older adults receiving appropriate treatment for high blood pressure, there should be a major effort aimed at increasing the number of patients who receive treatment. Previous studies on major intervention measures of antihypertensive treatment have indicated that it is important to lower blood pressure for all individuals with hypertension adults included.
Role of public health nurses
In order to reduce cases of patients abandoning medications for hypertension, public health nurses should provide consistent as well as appropriate follow-up for older adults under hypertensive medication (Fulmer & Zwicker, 2008). They should provide patient/caregiver education on benefits as well as risks associated with medication adherence in addition to potential side-effects of the medication. Besides, they have to monitor wrong choices among older adults with hypertension. Public health nurses also have to focus on providing non-pharmacologic hypertension treatment for both non-antihypertensive medication and antihypertensive medication patients so as to treat their emotional health. According to Berges, Markides, Ostir and Ottenbacher (2006) negative emotional health is highly associated with high blood pressure among older adults. Positive emotions help older adults cope with the changes their encounter in their late life. Public health nurses have to provide intensive nutritional education programs in order to ensure healthier diets among older adults which would help eliminate obesity and diabetes.
Aggregate at risk, extent and effect of hypertension
Many Americans in their late life tend to develop hypertension; however, this is not healthy aging. About 50,000 deaths as well as 535,000 hospitalizations are attributed to this condition (Arcury, Bell, Grzywacz, Quandt, Suerken and Lang, 2006), yet only a fraction of those who suffer from hypertension are actually aware and are treating it. Older adult women are more vulnerable as compared to older adult men. It is estimated that 83.5% women aged above 75 years and about 74% aged 65-74 suffer from hypertension while 69.2% older adult men above age 75 and 61% aged 65-74 suffer from the condition (Arcury et al., 2006). According to Carroll, et al. (2007) these rates have been increasing overtime. According to the National Health and Nutrition Examination survey conducted between 1988 and 2004, there was a 10% increase in prevalence between the periods 1988-1994 and 1999-2004 (Carroll et al., 2007). Non-Hispanic black women as well as men have higher prevalence as compared to other racial groups in the US. Prevalence is also higher among people from lower socio-economic backgrounds as compared to those of high socio-economic status (Banegas, Dominguez, Gutierrez-Fisac, Regidor and Rodriguez-Artelejo, 2006)). Older adults of lower socio-economic status are more vulnerable to stroke.
Arcury et al. (2006) estimated the total costs associated with high blood pressure to be over $59 billion while the American Hearts Associations believe that it has since increased to well over $93 billion. According to Hertz, Lustik, McDonald and Unger (2009) about 62% of the national healthcare budget is used to provide healthcare for heart conditions of older adults aged above 65 years although they only make up 12% of US’s total population. Cardiovascular risk reduction strategies that are applied to treat older adults are aimed at reducing morbidity and mortality. Although there is medical management guidelines as well as a variety of effective pharmacologic agents, the condition has not been effectively controlled among older adults particularly those above the age of 60. A small percentage of adults above age 60 under treatment for high blood pressure normally meet proper treatment guidelines. In addition, less than 30% of all individuals above 60 years who suffer from high blood pressure have effectively controlled blood pressure. There are many reasons attributed to this; however, the major cause of this is patient non-adherence to therapy is that patients find it difficult to adhere to potentially costs agents which also pose risks of side-effects. Therefore some older adults go for lower costs alternatives or those perceived to be safer. On an individual, high blood pressure shortens one’s life expectancy and compels the individual to change his or her lifestyle so as to control the risks associated with this condition. People with heart diseases have compromised functional activity, health status as well as participation in activities. Hypertension has also been found to affect people’s sleep time. According to Banegas, Faubel, Guallar-Castillon, Leon-Munoz, Lopez-Garcia and Rodriguez-Artalejo (2009) epidemiological studies have shown that older adults who sleep less than seven hours and those who sleep for more than 8 hours are more vulnerable to hypertension.
Community Programs
National programs
The US federal government has implemented several programs to help reduce risks associated with hypertension (Carroll et al., 2007). At the national level, the government implements all levels of prevention which include primary, secondary, tertiary as well as quaternary. Through its health department and other government health agencies, it provides education programs and publications on hypertension particularly on nutrition and other preventive measures, causes and treatment strategies as primary prevention measures. CDC funds Heart Disease and Stroke Prevention Program. It provides funds for the program so as to support it in developing effective strategies which could be useful for preventing as well as controlling stroke, heart disease among other risks associated with hypertension in all the 41 states together with the District of Columbia. The program aims to achieve stroke-free living as well as heart-healthy.
CDC State Heart Disease and Stroke Prevention Program provides finances to health departments in all these states as well as District of Columbia so as to support programs of heart-disease prevention through strategies aimed at changing physical as well as social environments and through education to reduce vulnerability to heart disease. The funds are also meant to implement strategies that help eliminate racial disparities in heart-disease risk. CDC also funds 15 WISEWOMAN projects across 14 states (Ayala, Croft, Denney, Greenlund & Keenana, 2007). WISEWOMAN provides women from lower socio-economic status; women who lack health insurance coverage as well as underinsured women aged 40-64 years with services meant to prevent cardiovascular disease. The services include cholesterol testing as well as blood-pressure screening. They also include life intervention programs such as physical activities, healthier diet and non-tobacco smoking. WISEWOMAN project provides its services through states and ethnic organizations. According to the Ayala et al. (2007) a comprehensive lifestyle modification approach targets alcohol intake, diet, exercise as well as salt intake to help control hypertension.
The national government also provides Cardiovascular Health Awareness Program particularly on cardiovascular disease at community levels. Beginning 1970 to 2008, a total of 36 community programs such as hypertension nutrition education and physical activity program offered through African American churches in Prince Georges County have been established with an aim of preventing cardiovascular disease (Centers for Disease Control and Prevention (b), 2011). The community programs aim at reaching adults aged 65 years and over with cardiovascular risks. The major aim of these community based programs is to reduce the rates of hospitalization for cardiovascular disease. Cardiovascular Health Awareness Program collaborates with the local stakeholders who include social and health services, community nurses, pharmacists, volunteers, family physicians as well as policymakers to ensure successful implementation of the program. They capitalize on and also coordinate the institutional as well as human assets of every community to achieve success. Health education programs are conducted in communities, hospitals as well as worksites in order to emphasize the significance of long-term control. This helps in patient awareness of hypertension and also help monitor patients.
The US Department of Health and Human Services established a network of Prevention research Centers in 1984 so as to help conduct and coordinate research in public health. The Prevention Research Centers (PRC) was to be administered by CDC. Currently, CDC supports about 37 public health centers across the country (Ayala et al., 2007). Each center has at least one core research project. The PRCs researches involve academic researchers, community members as well as public health agencies in researching ways that could help promote health as well as prevent diseases. Each PRC researches on how to better address behaviors as well as environmental factors which cause chronic diseases such as heart disease among others. The government as well as other agencies fund the projects. There are several institutions such as Dartmouth College responsible conducting research in cardiovascular health; University of North Carolina at Chapel Hill conducting programs aimed at changing behaviors together with appropriate adherence to therapy so as to reduce vulnerability to cardiovascular disease; University of Pittsburgh in collaboration with the Pennsylvania Department of Health provides education-plus-exercise program for adults as well as many institutions conducting research in obesity and other related causes of Hypertension. New York University School of Medicine also under the program and conducts research on reducing blood pressure among African-American men (Centers for Disease Control and Prevention (b), 2011).
It also provides secondary and tertiary prevention through funding of healthcare facilities and programs for diagnosing, treating as well as reducing the negative impacts of hypertension among older adults (Hertz et al., 2009). The federal government spends about 62% of its healthcare expenditure on hypertension related diseases among older adults (Hertz et al. 2009). State Heart Disease and Stroke Prevention Program is responsible for developing assessment tools which are used for tracking hypertension treatment as well as control rates. It does this through partnerships with federally-qualified health centers, primary care associations as well as managed care associations. It also collaborates with hospitals, local health departments, federally-qualified health centers as well as local minority nursing associations to detect as well as to control hypertension in high-risk groups through policy intervention as well as education programs. It also ensures that detection as well as follow-up services are made available for controlling hypertension and cholesterol through coordination with the American Heart Association, local health departments, employee organizations among other stakeholders (Ayala et al., 2007).
Other than the Prevention Research Centers, the national government also supports quaternary prevention through other research centers to develop new therapies for patients who suffer from disease that are as a result of hypertension; new strategies for identifying risk factors as well as new technologies for evaluating heart function.
Maryland State
The Office of Chronic Disease Prevention offers primary, secondary and tertiary prevention programs in Maryland through the Diabetes Control Program as well as Division of Cardiovascular Health & Nutrition. The primary prevention programs in all the jurisdictions in Maryland trough its Grants to Local Jurisdictions have been developed to increase physical activity, manage diabetes and hypertension as well as to improve eating habits. This program also ensures training of healthcare providers and conducting health assessments. Its Health, Communications, Education and Training program disseminates heart disease as well as stroke information through reports, CVD Newsletter, constantly updated websites and even through weekly radio shows and press releases. Finally, the community Prevention Efforts program involves with healthcare institutions concerned with cardiovascular disease prevention such as the Governor’s Council on Heart Disease and Stroke in mobilizing funds and facilitating policy as well as environmental changes (The Maryland Department of Health and Mental Hygiene Family Health Administration Office of Chronic Disease Prevention, 2009).
The Office of Chronic Disease Prevention of Maryland through the Diabetes Control Program as well as Division of Cardiovascular Health & Nutrition focuses its secondary and tertiary prevention approach on the high-risk African American population through Maryland hospitals and other healthcare facilities and institutions (The Maryland Department of Health and Mental Hygiene Family Health Administration Office of Chronic Disease Prevention, 2009). Division of Adult and Geriatric Adult Health Program of Maryland Country provides several healthcare programs aimed at achieving healthy aging by providing; high quality clinical care and geriatric medicine training to clinical trainees as well as by conducting continuous health research to advance knowledge in healthcare. It provides clinical programs such as the House Call Program, Hospital Based Services, the Palliative Care Consultation Service, Research as well as other programs. The House Call Program provides medical care services to older adults who suffer from chronic disease as well as mobility impairment and therefore are not able to travel to the Wright Center. Hospital Based Services offers Geriatric Consultation Services to other doctors working in the hospitals on how to deal with the older adults who have been hospitalized and require special needs. It also offers Acute Care for the Elderly inpatient program. The Palliative Care Consultation Service provides supportive care for older adults in areas such symptom management, pain as well as medical treatment. The research program also conducts research projects to advance knowledge in aging. Just like the Cardiovascular Health Awareness Program established by the national government, it also engages the community and also provides several educational programs to make the program more clinically relevant. The education program also provides training to physicians and those in clinical practice on geriatric care. Besides, it also has several research centers just like it is at the national level; however, its research centers are limited in scope as compared to the national level programs (The Maryland Department of Health and Mental Hygiene Family Health Administration Office of Chronic Disease Prevention, 2009).
Baltimore, Maryland
Most prevention activities in Baltimore, Maryland are primary which include hypertension management, nutrition education and physical activity. Information dissemination is conducted through a network of African American churches, media and community sites (The Maryland Department of Health and Mental Hygiene Family Health Administration Office of Chronic Disease Prevention, 2009). There has also been huge investment on research just like in the other two administrative levels. In attempts to reduce risks associated with high blood pressure, Johns Hopkins Medical School in Baltimore conducts research on alternative therapies as well as preventive strategies that could be used to achieve healthy living. They established that daily consumption of 3gms of fish is a valuable therapy for patients affected by borderline personality. They have also proved that potassium supplementation during treatment as well as prevention of hypertension helps lower blood pressure. They have also demonstrated that eating vegetables and fruits as well as low-fat dairy products effectively control blood pressure. Researchers at Johns Hopkins Medical School also conduct research on aerobics (The Maryland Department of Health and Mental Hygiene Family Health Administration Office of Chronic Disease Prevention, 2009).
Assessment of programs/resources
The health programs implemented throughout the US administrative systems are adequate considering that they are take care of all levels of prevention. Besides, they are provided at all levels and most importantly at community levels making it easier to reach the patients, detect hypertension and provide health care services. The resources and programs also strive to research new strategies and technologies for reducing the condition at every community level and also involve the community in research programs. All the administrative levels provide funding to support healthcare facilities and programs aimed at preventing, reducing and treating of hypertension and associated diseases.
Conclusion
Hypertension prevalence among older adults in the US , especially among the African American population is very high and is still projected to increase if proper preventive and treatment strategies are not implemented and adopted by the healthcare providers as well as individuals. Hypertension impacts on the health of the older adults and causes high costs expenditure on healthcare both to the individual and all the levels of government in the US. In addition, it reduces life expectancy and increases mortality rates among older adults. Adopting healthier diet and lifestyle modification could help individuals prevent risks associated with hypertension. Prevention and treatment programs should therefore be coordinated at all levels beginning from the national to community levels.
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