Managing Hypertension among the Elderly in Nursing Homes

Evidence-Based Practice: Cardiovascular disease is one of the top causes of disability and death in elderly patients aged above 50 years. In most cases, elderly patients diagnosed with hypertension are prescribed hypertension medications that are key to maintaining a normal blood pressure, as well as reduce the risk for other cardiovascular risks. Son et al. (2017) posit that high blood pressure is one of the most vital risk factors for cardiovascular disease. In addition, about 54% and 47% of strokes and coronary heart diseases, respectively, are associated with high blood pressure. Old age is usually associated with an increased risk for high blood pressure, making it a challenge among elderly patients in nursing homes. Thus, it is crucial to develop healthcare regimens and adopt guidelines that help lower blood pressure and reduce the risk for cardiovascular disease in this population. This paper will focus on evidence-based research that can be implemented to improve the outcomes of elderly patients with hypertension, with the help of staff and nurses . The breakdown of the EBP problem is as follows:

Population: Female elderly patients with hypertension.

Intervention: Exercise and diet change

Comparison: Hypertension medication only

Outcome: Reduced blood pressure and fewer cardiovascular complications

Time: Three months.

Given the PICO framework above, the EBP question in this case is as follows:

EBP question:  In female elderly patients with hypertension, does exercising result in fewer cardiovascular complications and reduced blood pressure compared to only taking medication within a 3-month period?

Research-based Article

After searching in several scholarly journals, the research-based article that appeared to be most suitable for answering the above-mentioned EBP question is Son et al. (2017) titled “Combined exercise reduces arterial stiffness, blood pressure, and blood markers for cardiovascular risk in elderly patients with hypertension.” This study aims to investigate the impact of combined aerobic and resistance exercise training on branchial-ankle pulse wave velocity (baPWV), which indicates arterial stiffness), and overall heart health in elderly patients with hypertension. According to the study, elderly patients are at a high risk of arterial stiffness and an overall decline in muscle strength owing to the age-related changes in structural and functional aspects of the body. Together, these factors contribute to increased probability of cardiovascular disease, in elderly patients with hypertension.

Son et al. (2017) use a randomized controlled trial design whereby 20 elderly patients aged 75 years and above were randomly assigned to two study groups with 10 participants each: combined exercise (EX) and no-exercise (CON). Participants in the EX group performed aerobic and resistance training exercises for 12 weeks, three times every week. Every four weeks, the exercise intensity level was increased base on heart rate reserve parameters. Key elements were measured before and after the intervention including BP, BaPWV, endothelin-1, blood nitrate/nitrite, body composition and cardiovascular fitness.

After using the Johns Hopkins Nursing Evidence-Based Practice Research appraisal model, this study was determined to be a Level 1 (randomized controlled trial. In addition, the rating of the study is A (High quality) owing to key defining factors such as consistent and generalizable results, adequate control, a comprehensive literature review and conclusions that are definitive. In addition, the study includes intensive reference to scientific literature, which adds on to the suitability of the study in answering the EBP question.

The researchers use several data analysis tools including the unpaired t test to establish differences between the two study groups at baseline and a two-way ANOVA with repeated measures to compare differences before and after the intervention. The statistical analysis software used is the SPSS 18.0. For example, body composition was evaluated pre and post combined  exercise training in both the EX and CON group.  The study design was approved by the Institutional Review Board of the Public Institutional Review Board by the Ministry of Health and Welfare, and it was performed in accordance with the Declaration of Helsinki. Considering the fact that the study involved humans, the authors obtained written informed consent from all participants prior to the study.

According to the results from the study, the participants in the EX group registered reduced body fat percentage, better physical fitness, lower arterial stiffness and systolic and diastolic BP over the course of three months compared to the control group. Therefore, the finding that combined anaerobic and aerobic exercise decreases blood pressure, arterial stiffness , blood endothelin-1 while increasing nitrate/nitrite levels in elderly patients with stage 1 hypertension is a valuable insight into ways hospitals can offer healthcare solutions to female elderly patients with hypertension. Moreover, the study findings indicate that elderly patients with hypertension can achieve better health with regular exercise, at least three times per week. Thus, the article sufficiently answers the EBP question.

Non-Research Article

There are numerous non-research articles hypertension online, mostly offering guidelines on how elderly patients with hypertension can live a healthier life. In particular, “Women and Hypertension: Beyond the 2017 guideline for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults” provides an excellent outlook on how increasingly higher rates of hypertension are observed in women after menopause owing to fluctuating levels of estrogen (Abramson et al., 2018). It has been established that the loss of estrogen associated with the body’s transition into menopause could lead to cardiovascular disease. In addition, this biological change has also been associated with the likelihood for women in post menopause to benefit from physical training. Herein, the article includes highlights of studies on cardiovascular health and elderly patients. The study also highlights the efficacy of the current guidelines whereby elderly patients are advised to monitor their blood pressure, which could potentially lead to improved BP control.

According to “Appendix F: Non-Research Evidence Appraisal” by JHNEBP model, the article is “Consensus or Position Statement Level V” as it provides a summary of published literature including expert opinion to guide clinicians in decision-making for treatment for elderly patients with hypertension. In addition to summarizing the main findings of a previous study, the article presents expert opinions for women in the field. After performing the appraisal, the quality rating of this article is B (Good Quality).

The study offers both pharmacological and non-pharmacological interventions for hypertension. One of these recommendations is diuretic therapy, which is reported to be beneficial in preventing stroke compared to use of ACE inhibitors. Notably, the author recommends that weight loss strategies could be beneficial for older women with hypertension. In addition, both weight loss and diet interventions are recommended, with these two showing increased benefits in lowering cardiovascular biomarkers and blood pressure. Therefore, this article answers the EBP question by providing valuable recommendations drawn from numerous scientific and non-scientific sources. Ultimately, the article concludes that the crucial role of cardiovascular fitness in improving long term cardiovascular outcomes is well established, as well as exercise.

Gynecologists and cardiologists in nursing homes should join efforts in advising elderly patients with hypertension on the benefits of aerobic and anaerobic exercise in lowering blood pressure. While prescribing hypertensive medications might be necessary to manage hypertension, patients should be weaned off the prescriptions in follow-up regimes where patients are required to exercise at least three times a week. Through this integrated approach, there will be an opportunity for female elderly patients to achieve better health outcomes included a normal blood pressure and cardiovascular fitness. In order to achieve this practice change, medical officers, nurses, and the patient would need to work collaboratively in order to support the change. In most cases, patients under hormone therapy might get a chance to reduce the number of medications needed to manage severe symptoms.

Although the above-mentioned recommendation is based on scientific evidence, most elderly patients might not be aware about the benefits of exercise on managing hypertension. Therefore, I would have to launch a sensitization campaign targeting this particular population in nursing homes. For instance, I would distribute small brochures at strategic locations such as in their rooms where patients can access them. Nurses would play a role in following up on patients’ exercise routines. In order to measure the impact such a change would have, patient’s blood pressure and other cardiovascular markers would be assessed during follow-up visits to establish the effectiveness of the intervention. Where a follow up session is not available, patients can comfortably use portable devices at the comfort of their home, and share the results via established telehealth channels.