Arterial hypertension diagnostic and drug therapy failure among Brazilian elderly – FIBRA Study

Mariana Reis Santimaria Flávia Silvia Arbex Borim Daniel Eduardo da Cunha Leme Anita Liberalesso Neri André Fattori About the authors

Resumo

O objetivo deste estudo foi investigar prevalências de falhas no diagnóstico, no uso de anti-hipertensivos e na eficácia do tratamento medicamentoso da hipertensão, e a associação destes parâmetros com variáveis sociodemográficas, de saúde e acesso ao serviço de saúde em idosos não institucionalizados. O estudo foi descritivo, transversal, com 3478 idosos, analisados separadamente em regiões Norte/Nordeste e Sul/Sudeste. Utilizou-se a regressão múltipla de Poisson para estimar razões de prevalência brutas e ajustadas pelo tipo de serviço de saúde utilizado. Do total, 29,6% dos idosos apresentaram falhas no diagnóstico, 4,6% no uso de anti-hipertensivos e 65,3% na eficácia medicamentosa. A falha no diagnóstico associou-se ao sexo masculino, menos morbidades, ter um companheiro, raça/cor branca, ter acesso ao convênio ou serviço privado de saúde, possuir renda pessoal inferior/média e ainda trabalhar. A falha no uso de anti-hipertensivos esteve associada à renda pessoal inferior/média e trabalhar. As falhas no manejo da hipertensão são prevalentes em idosos não institucionalizados. Há necessidade de ações que minimizem os impactos negativos destas insuficiências em saúde, em um país com diferenças sociais, econômicas e étnicas.

Palavras-chave
Hipertensão; Idoso; Acesso aos serviços de saúde; Vulnerabilidade em saúde

Abstract

This study aimed to investigate the prevalence of failure in hypertension diagnosis, antihypertensive drug use and drug therapy efficacy and the association of these parameters with sociodemographic, health-related and access to health services variables in community-dwelling elderly. This is a descriptive cross-sectional study with 3,478 elderly from different Brazilian regions. We used Pearson’s chi-square test to verify associations between outcomes and independent variables, and Poisson multiple regression to estimate crude and adjusted prevalence ratios. Of the total, 29.6% of the elderly evidenced failure in the diagnosis, 4.6% in the use of antihypertensives and 65.3% in drug efficacy. Diagnostic failure was associated with males, presence of morbidity, having a partner, white skin color/ethnicity, having access to the health covenant or private health service, with low/medium personal income and working. Antihypertensive use failure was associated with low/medium personal income and work. Hypertension management failures are prevalent in community-dwelling elderly. There is a need for actions that minimize the negative impact of these health shortcomings, in a country burdened by social, economic and ethnic differences.

Key words
Hypertension; Elderly; Access to health services; Vulnerability in health

Introduction

Ageing generates progressive changes in the organic systems, which determine the loss of adaptability to the environment, increased vulnerability and probability for the development of chronic degenerative diseases, among which is systemic arterial hypertension (SAH), a prevalent clinical condition among the elderly population11 Pimenta FB, Pinho L, Silveira MF, Carvalho BAC. Fatores associados a doenças crônicas em idosos atendidos pela Estratégia de Saúde da Família. Cien Saude Colet 2015; 20(8):2489-2498..

According to data from the 2013 National Health Survey22 Andrade SSA, Stopa SR, Brito AS, Chueri PS, Szwarcwald CL, Malta DC. Prevalência de hipertensão arterial autorreferida na população brasileira: análise da Pesquisa Nacional de Saúde, 2013. Epidemiol. Serv. Saude 2015; 24(2):297-304., the prevalence of self-reported hypertension in people aged 60-64 years was 44.4%. In the more advanced age groups of 65-74 years and 75 years and over, hypertensive rate was higher at 52.7% and 55.0%, respectively. Moreover, distribution was unequal between genders, with an increasing trend among older women.

Hypertension is frequent and an important risk factor for cardiovascular events and is associated with functional disability and death in the elderly33 Aronow WS. Treating hypertension and prehypertension in older people: When, whom and how. Maturita 2015; 80(1):31-36.. While mortality due to cardiovascular diseases has shown a decreasing trend in recent years, SAH early diagnosis is fundamental for the establishment of actions that ensure disease control and prevent complications44 Costa KS, Tavares NUL, Mengue SS, Pereira MA, Malta DC, Silva Júnior JB. Obtenção de medicamentos para hipertensão e diabetes no Programa Farmácia Popular do Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saude 2016; 25(1):33-44..

The literature evidences improved access to hypertension treatment in Brazil55 Serrate MS, Dâmaso BA, Ramos LR, Farias MR, Auxiliadora OM, Urruth LTN, Arrais PSD, Luiza VL, Pizzol TSD. Acesso e uso de medicamentos para hipertensão arterial no Brasil. Rev Saude Publ 2016; 50(2):8s.; however, coverage is still inadequate, with low control rates66 Barreto M, Cesse E, Lima R, Marinho M, Specht Y, Carvalho E, A Fontbonne. Análise do acesso ao tratamento medicamentoso para hipertensão e diabetes na Estratégia de Saúde da Família no Estado de Pernambuco, Brasil. Rev Bra. Epidemiol 2015; 18(2):413-424.. The understanding of conditions that underpin shortcomings in the diagnosis and treatment of hypertension enables the analysis of access to services and treatment and equity, favoring prevention, health promotion and education actions.

Thus, this study aimed to investigate the prevalence of failure in SAH diagnosis, regular antihypertensive drug use and drug therapy efficacy and the association of these parameters with sociodemographic, functional capacity, multimorbidity and non-institutionalized elderly access to health services variables.

Methods

This is a cross-sectional descriptive study of data from the main multicenter project called FIBRA (Brazilian Elderly Frailty) – Unicamp complex, which aimed to identify community-dwelling elderly’s frailty conditions and was approved by the Research Ethics Committee of the Faculty of Medical Sciences of Unicamp77 Neri AL, Yassuda MS, Araújo LF, Eulálio MC, Cabral BE, Siqueira MEC, Santos GA, Moura JGA. Metodologia e perfil sociodemográfico, cognitivo e de fragilidade de idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Cad Saude Publica 2013; 29(4):778-792..

In total, 3,478 elderly from different locations, selected by simple random sampling from urban census tracts of cities chosen through convenience sampling were evaluated. In order to calculate the sample size, a sampling error of 4% was accepted for cities with more than 1 million inhabitants (601 elderly in Campinas, São Paulo and Belém, Pará) and 5% in those with a population of less than 1 million of inhabitants (235 elderly in Ivoti, Rio Grande do Sul and 384 elderly in the remaining cities). The number of elderly included in each census tract observed the distribution proportionality in the age groups of 65-69, 70-74, 75-79 and more than 80 years, according to the number of elderly of these segments in the urban population of each city88 Instituto Brasileiro de Geografia e Estatística (IBGE). [acessado 2017 jul 14]. Disponível em http://www.ibge.gov.br
http://www.ibge.gov.br...
. The number of census tracts drawn and recruited and the definition of regions for the comparative analyses were: South/Southeast, consisting of the municipalities of Campinas, São Paulo (90 census tracts), Poços de Caldas, Minas Gerais (75 census tracts), Ivoti, Rio Grande do Sul (27 census tracts) and sub-district Ermelino Matarazzo, São Paulo (62 census tracts); North/Northeast, consisting of municipalities of Belém, Pará, (93 census tracts), Parnaíba, Piauí (60 census tracts) and Campina Grande, Paraíba (60 census tracts). The recruitment of elderly was not epidemiologically perfect within each census tract.

Inclusion criteria were age 65 years and over, understanding the instructions, agreeing to participate and being a permanent resident at home and in the census tract. Exclusion criteria were severe cognitive impairments suggestive of dementia, wheelchair use or being temporarily or permanently bedridden, suffering from severe sequelae of stroke, having Parkinson’s disease, being a carrier of severe hearing or vision impairment, seriously compromising communication and being in a terminal stage99 Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA, Cardiovascular Health Study Collaborative Research Group. Frailty in older adults evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56(3):146-157.,1010 Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB, Walston JD. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc 2004; 52(4):625-634..

Recruitment included two stages, the first of which was information to the community involved, with lectures and announcements in the media. The second consisted of recruiters’ visits to the elderly. The elderly who were recruited moved on to the data collection stage in a previously scheduled place, date and time. Data collection sessions ranged from 40 to 120 minutes. The elderly were informed about FIBRA study’s characteristics and signed the Informed Consent Form if they agreed to participate.

Elderly participants were referred to an interviewer for the first stage of data collection and were submitted to measurement of socioeconomic and demographic variables, anthropometric measures, blood pressure, frailty and cognitive status by MMSE1111 Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12(3):189-198.. Cutoff points used to define cognitive impairment by MMSE were 17 for the illiterate; 22 for the elderly with 1-4 years schooling; 24 for those with 5-8 years schooling; and 26 for those with 9 years or more schooling1212 Brucki SM, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr 2003; 61(3):777-781..

Individual scores below the cutoff point for their level of schooling participated only in the first stage of data collection and then were dismissed. Elderly scoring above the cutoff points in the MMSE measured variables collected in the first stage and self-reported measures about functional physical conditions, care and psychosocial variables77 Neri AL, Yassuda MS, Araújo LF, Eulálio MC, Cabral BE, Siqueira MEC, Santos GA, Moura JGA. Metodologia e perfil sociodemográfico, cognitivo e de fragilidade de idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Cad Saude Publica 2013; 29(4):778-792..

All the information was collected and recorded by trained interviewers, and sociodemographic variables age, gender, skin color/ethnicity, personal income, current work status and marital status were selected for this study. Variable “morbidities” was also selected and was characterized by the number of diseases reported through the question: “Has any doctor ever diagnosed any of the diseases listed?”, and classified in two categories (one disease or two and more chronic diseases).

Regarding functional capacity, independence levels for basic activities of daily life (BADL)1313 Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. Jama 1963; 185(12):914-919. and instrumental activities of daily living (IADL)1414 Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Nursing Research 1970; 19(3):278. were investigated, and the elderly reporting that they did not need help for any activity were classified as independent and those who reported needing partial or total help for one or more activities were classified as dependent.

Access to the health service was defined as the type of health service frequently used and reported by the elderly in the interview (public health services, covenants, private health plans and private services paid directly by the patient).

The “blood pressure” (BP) variable was obtained through three consecutive measurements of systolic blood pressure (SBP) and diastolic blood pressure (DBP) in a sitting position, with the arm supported at the approximate height of the heart. Measurements were performed at 1-minute intervals, according to the Brazilian Hypertension Guideline recommendations77 Neri AL, Yassuda MS, Araújo LF, Eulálio MC, Cabral BE, Siqueira MEC, Santos GA, Moura JGA. Metodologia e perfil sociodemográfico, cognitivo e de fragilidade de idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Cad Saude Publica 2013; 29(4):778-792.,1515 Malachias MVB, Póvoa RMS, Nogueira AR, Souza D, Costa LS, Magalhães ME. 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 2 - Diagnóstico e Classificação. Arq Bras Cardiol 2016; 107(Supl. 3):7-13., using the Omron HEM-705 CP IT® sphygmomanometer. The elderly were instructed to do bladder emptying before measurements and placed in a comfortable 5-minute rest in a seated position. They were also instructed to avoid coffee consumption, smoking and high food intake before the interview. Simple means were calculated from the values obtained and then recorded as continuous values, in mmHg. The classification of SAH was based on SBP and DBP means. Individuals with mean SBP>140 mmHg and DBP>90 mmHg were classified as hypertensive, those with mean SBP>140 mmHg and DBP<90 mmHg as patients with isolated systolic hypertension (ISH) and those with means of SBP<140 mmHg and DBP<90 mmHg1515 Malachias MVB, Póvoa RMS, Nogueira AR, Souza D, Costa LS, Magalhães ME. 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 2 - Diagnóstico e Classificação. Arq Bras Cardiol 2016; 107(Supl. 3):7-13. as normotensive patients.

The following dependent variables were created: (1) Failure in the diagnosis of hypertension, defined by the record of arterial hypertension in an individual who did not self-declare as hypertensive; (2) Failure in the use of regular medications for SAH, corresponding to the elderly who declared themselves hypertensive, but did not use antihypertensive medication; (3) Failure in the effectiveness of the drug treatment, by self-reported hypertension among participants taking antihypertensive medication, but with high BP values at the time of collection (those classified with SAH and ISH).

All analyses were performed by statistical program Stata® SE version 14.0. Associations between variables were verified by Pearson’s chi-square test with a significance level of 5%. Then, a Poisson regression analysis was performed with robust, crude and adjusted variance (by type of service used, that is, private or public service users, since access to services was associated with income), with prevalence ratio (PR) and respective 95% confidence intervals (95% CI). We chose this statistical model because the dependent variables are highly prevalent in the population and because this cross-sectional study used prevalence ratio as a measure of association.

Results

According to the sample studied, elderly’s mean age was 72.9 years, and 67.6% were women and most (53.75%) resided in the South/Southeast regions of the country. Table 1 shows the distribution of the dependent variables; 29.6% had diagnostic failure, 4.6% showed failure in the use of medication and 65.3% had failed efficacy (Table 1).

Table 1
Percentage distribution of the variables diagnostic failure, failure in the use and efficacy of antihypertensive drugs, according to regions. FIBRA 2008/09.

Considering diagnostic failure, we observed a higher prevalence in the male elderly, with a personal income of up to three minimum wages, who worked, lived with a partner, had one morbidity and were private health services users (Table 2). Specifically, in the South/Southeast regions, the highest prevalence ratios for diagnostic failure were individuals who worked and used private health services, and lower prevalence rates were among black/mulatto females living without partners and reporting two or more morbidities (Table 2). In the North/Northeast regions, lower prevalence ratios were found for females, with an income of 1-3 minimum wages and reporting two or more morbidities (Table 2).

Table 2
Prevalence of diagnostic failure and prevalence ratio, according to sociodemographic, health and access to health service variables in community-dwelling elderly. FIBRA 2008/09.

Table 3 shows a higher prevalence of failure to use antihypertensive medication in male elderly and in those who worked. Furthermore, in the South/Southeast regions, the highest prevalence rate for drug use failure occurred among those who worked, a result also found in the North/Northeast regions, in addition to the significance maintained among elderly individuals receiving 1-3 minimum wages (MW).

Table 3
Prevalence of failure in the use of antihypertensive drugs and prevalence ratio, according to sociodemographic, health and access to health service variables in community-dwelling elderly. FIBRA 2008/09.

SAH drug therapy efficacy failure showed a higher prevalence for males aged 75 years and older, not mentioning being white and having up to one morbidity; on the other hand, reporting monthly income of 1-3 MW showed lower prevalence in relation to the reference category (Table 4).

Table 4
Prevalence of drug therapy failure and prevalence ratio, according to sociodemographic, health and access to health service variables in community-dwelling elderly. FIBRA 2008/09.

Discussion

SAH is a widely studied clinical condition; however, little is known about the factors associated with the lack of knowledge of the diagnosis of hypertension, failures in the use of antihypertensive drugs and the efficacy of drug therapy among hypertensive patients. Understanding the determinants of these shortcomings is a challenge.

In this context, this study showed the expressive failure prevalence of 29.6% and 65.3% for diagnosis and hypertension treatment efficacy, respectively, in non-institutionalized elderly people living in different Brazilian regions. Specifically, the lack of knowledge of the disease diagnosis was associated with males, presence of one morbidity, having a partner, white skin color/ethnicity, access to covenant or private health services, low and medium personal income and working. In addition, antihypertensive drug use failure was significantly associated with low and medium income and working. Notably, the main results also showed dissimilarities in these associations, according to the regions studied.

Previous data show the extent of shortcomings in SAH diagnosis and treatment in Brazil. It is estimated that one third of the hypertensive population is unaware of the clinical diagnosis of the disease and, among diagnosed, only 30% check their pressure1616 Zattar LC, Boing AF, Giehl MWC, d'Orsi E. Prevalência e fatores associados à pressão arterial elevada, seu conhecimento e tratamento em idosos no sul do Brasil. Cad Saude Publica 2013; 29(3):507-521.. Despite medical advances in recent years, there is a need to pay more attention to these failures, especially among the elderly, because they have high rates of hypertension and are more vulnerable.

In a recent study, Bezerra et al.1717 Bezerra VM, Andrade ACS, César CC, Caiaffa WT. Desconhecimento da hipertensão arterial e seus determinantes em quilombolas do sudoeste da Bahia, Brasil. Cien Saude Colet 2015; 20(3):797-807. showed the difficulty in accessing the diagnosis and treatment of hypertension in Brazilians with greater social and health vulnerabilities. The sample consisted of 350 participants with a wide age group (18 years and over) of quilombola communities. Authors noted that more than 30% of hypertensive patients were unaware of the diagnosis of SAH and pointed out that there was a positive association between the lack of knowledge of stage 1 SAH disease and males.

Corroborating these findings, our study evidenced a higher prevalence in the lack of knowledge of hypertension in elderly men, for all regions included in the study. It is known that due to behavioral and cultural issues, men seek health services less frequently and have fewer consultations. Awareness of treatment and prevention is still typically female1818 Gee ME, Bienek A, McAlister FA, Robitaille C, Joffres M, Tremblay MS, Johansen H, Campbell NR. Factors associated with lack of awareness and uncontrolled high blood pressure among Canadian adults with hypertension. Can J Cardiol 2012; 28(3):375-382.

19 Valle TGM, Melchiori LE, organizadores. Saúde e desenvolvimento humano. São Paulo: Editora UNESP; 2010.
-2020 Costa-Júnior FM, Couto MT, Maia ACB. Gênero e cuidados em saúde: Concepções de profissionais que atuam no contexto ambulatorial e hospitalar. Sexualidad, Salud y Sociedad 2016; (23):97-117..

Diagnostic failure in the North/Northeast and South/Southeast regions was also higher among individuals with only one reported chronic disease. The hypothesis for this result consists in the attitudes of greater needs and search for health services among patients with simultaneous diseases, consequently increasing the probability of knowing the diagnosis1717 Bezerra VM, Andrade ACS, César CC, Caiaffa WT. Desconhecimento da hipertensão arterial e seus determinantes em quilombolas do sudoeste da Bahia, Brasil. Cien Saude Colet 2015; 20(3):797-807.,2121 Hu Y, Wang Z, Wang Y, Wang L, Han W, Tang Y,Xue F. Hou L, Liang S, Zhang Biao, Wang W, Asaiti K, Pang H, Zhang M, Jiang J. Prevalence, Awareness, Treatment, and Control of Hypertension among Kazakhs with high Salt Intake in Xinjiang, China: A Community-based Cross-sectional Study. Sci Rep 2017; 7:45547.,2222 Nunes BP, Soares MU, Wachs LS, Volz PM, Saes MO, Duro SMS, Thumé E, Facchini LA. Hospitalization in older adults: association with multimorbidity, primary health care and private health plan. Rev Saude Publica 2017; 51:43.. Studies carried out at the national2323 Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care 2008; 46(9):930-937. and international levels2424 Wang HH, Wang JJ, Lawson KD, Wong SY, Wong MC, Li FJ, Wang PX, Zhou ZH, Zhu CY, Yeong YQ, Griffiths SM, Mercer SW. Relationships of multimorbidity and income with hospital admissions in 3 health care systems. Ann Fam Med 2015; 13(2):164-167. show the trend of greater demand for medical care among the elderly with multimorbidity, and this clinical condition is related to greater risks of complications and unfavorable outcomes in the more advanced age groups.

Again, in the total population, a higher prevalence of diagnosis failure was observed among the elderly with partners. However, interestingly, the South/Southeast regions showed a lower prevalence of the lack of knowledge of SAH among those who had no partners. These results are in agreement with a previously published study2525 Esperandio EM, Espinosa MM, Martins MSA, Guimarães LV, Lopes MAL, Scala LCN. Prevalência e fatores associados à hipertensão arterial em idosos de municípios da Amazônia Legal, MT. Rev. Bras. Geriatr Gerontol 2013; 16(3):481-493., in which it identified the highest rates of SAH reported in unmarried or single elderly. In addition, authors emphasized that life without a partner interferes with emotional well-being and hastens the onset of chronic diseases, and in these cases of health vulnerabilities, medical demand is more frequent and would be related to greater knowledge of the diagnosis of the disease.

Black, caboclo, mulatto and brown were negatively associated with diagnostic failure in the South/Southeast regions. It is suggested that there is a greater preparation of network health professionals in relation to the epidemiological characteristics of SAH in the more developed regions. Another hypothesis is the high percentage of black and mainly brown individuals in the north and northeast of Brazil2626 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos Indicadores Sociais. Rio de Janeiro; 2015., and this factor may have influenced the regression analysis, mitigating statistical differences through lower ethnicity variability.

Again, in relation to the South/Southeast, interestingly, the covenant and private health service was associated with the diagnostic failure. It is well known that the public health system has some shortcomings, such as difficult access to services; frequent impossibility of scheduling and choosing professionals/providers; long waiting list for elective surgeries and especially low supply of diagnostic and therapeutic support services. These limitations lead the population to disbelief in the public service, and many seek private services, health plans or insurers, especially the elderly for reasons of greater need and use2727 Soares SI, Dominguez UMA, Porto SM. O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde. Cien Saude Colet 2008; 13(5):1431-1440.. However, the current Brazilian health system has notable advances in the provision of programs, projects, policies and increased coverage with relevant results. These advances are also understood as a new comprehensive look at the patient, characterized by interdisciplinarity that goes against fragmented treatment in specialties, in which it is common in health covenants2828 Mendes EV. 25 anos do Sistema Único de Saúde: resultados e desafios. Estud. Av 2013; 27(78):27-34.

29 Souza GCA, Costa ICC. O SUS nos seus 20 anos: reflexões num contexto de mudanças. Saude Soc 2010; 19(3):509-517.
-3030 Telesi Júnior E. Práticas integrativas e complementares em saúde, uma nova eficácia para o SUS. Estud Av 2016; 30(86):99-112..

However, in spite of progress, access to health is still inadequate, selective and exclusionary in many cases, with socioeconomic and geographical hurdles in relation to the guarantee of universality3131 Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cien Saude Colet 2012; 17(11):2865-2875.,3232 Viegas APB, Carmo RF, Luz ZMP. Fatores que influenciam o acesso aos serviços de saúde na visão de profissionais e usuários de uma unidade básica de referência. Saude Soc 2015; 24(1):100-112.. In fact, in this research in less socioeconomically favored regions (North and Northeast), low and medium income is highlighted as a relevant factor in the diagnostic failure of hypertension and in the use of antihypertensive medication. The literature emphasizes that in countries with unequal income distribution, both low and medium income groups suffer from the worst health situation; on the other hand, in regions where a society is equitable, even the poorest groups have a better health status3333 Buss PM, Pellegrini Filho A. Iniqüidades em saúde no Brasil, nossa mais grave doença: comentários sobre o documento de referência e os trabalhos da Comissão Nacional sobre Determinantes Sociais da Saúde. Cad Saude Publica 2006; 22(9):2005-2008.,3434 Almeida AR, Athayde FTS. Promoção da saúde, qualidade de vida e iniquidade em saúde: reflexões para a saúde pública. Tempus Actas de Saude Coletiva 2016; 9(2):165-172..

Interestingly, work activity in old age was also an important factor in the level of failure in the diagnosis and the use of antihypertensive drugs in the evaluated regions. It is worth remembering that Brazilian elderly are increasingly introduced in the labor market. According to data from the Brazilian Institute of Geography and Statistics (IBGE), in 2012, people aged 60 and over held 27% of jobs, with a progressive rate increase trend for the coming years3535 Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos Indicadores Sociais. Rio de Janeiro: IBGE; 2013..

Although work means occupation and a sense of usefulness in society, for some elderly people, retirement allows free time for self-care and many of them enjoy this benefit by performing pleasurable activities and self-care. The idle period is related to the opportunity to perform physical activities and search for medical care3636 Santos GA, Vaz CE. Grupos da terceira idade, interação e participação social. In: Zanella AV, Siqueira MJT, Lhullier LA, Molon SI, organizadoras. Psicologia e práticas sociais [online]. 2008 [acessado 2017 jul 14]. Disponível em: http://books.scielo.org/id/886qz/pdf/zanella-9788599662878-31.pdf
http://books.scielo.org/id/886qz/pdf/zan...
.

The variable failed drug therapy efficacy did not obtain the same statistical effect of association observed in the aforementioned outcomes. It is worth noting the difficulty of analyzing the BP variable, based on BP in loco measurements, which are subject to the variability resulting from the psychological aspects of participants at the time of screening, such as “white coat hypertension”; even if plausible, now potential bias, the proportion of failed efficacy in the total sample is high. In addition, our study did not analyze non-pharmacological measures such as diet, physical exercise and health education, in relation to the management of hypertension in the studied population. We understand that the treatment of hypertension is based on all pharmacological and non-pharmacological treatment modalities, which are complementary and influential in the control of pressure levels.

The limitation of this research is the cross-sectional design of this study, which does not allow us to describe cause and effect relationships from the analyzed variables. More than identifying risk factors, it is necessary to further study the longitudinal relationship between the social and health determinants involved in the SAH health/disease process. Another critical point is that the timely measurement of blood pressure, even if done systematically and according to the best consensuses, may not accurately represent the blood pressure condition of these elderly patients in their usual environment. However, this is a common condition for blood pressure studies, which does not minimize the importance of the findings.

Conclusion

Failures in the diagnosis of SAH and in the use and efficacy of antihypertensive drugs were prevalent in community-dwelling elderly. Above all, differences in the prevalence of failures among Brazilian regions, through social, economic and ethnic aspects reflect health shortcomings in the most vulnerable groups of the elderly, which deserve special attention. Measures are required to enable adequate screening and treatment of hypertension in a territorially extensive country with socioeconomic differences and intense miscegenation.

References

  • 1
    Pimenta FB, Pinho L, Silveira MF, Carvalho BAC. Fatores associados a doenças crônicas em idosos atendidos pela Estratégia de Saúde da Família. Cien Saude Colet 2015; 20(8):2489-2498.
  • 2
    Andrade SSA, Stopa SR, Brito AS, Chueri PS, Szwarcwald CL, Malta DC. Prevalência de hipertensão arterial autorreferida na população brasileira: análise da Pesquisa Nacional de Saúde, 2013. Epidemiol. Serv. Saude 2015; 24(2):297-304.
  • 3
    Aronow WS. Treating hypertension and prehypertension in older people: When, whom and how. Maturita 2015; 80(1):31-36.
  • 4
    Costa KS, Tavares NUL, Mengue SS, Pereira MA, Malta DC, Silva Júnior JB. Obtenção de medicamentos para hipertensão e diabetes no Programa Farmácia Popular do Brasil: resultados da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saude 2016; 25(1):33-44.
  • 5
    Serrate MS, Dâmaso BA, Ramos LR, Farias MR, Auxiliadora OM, Urruth LTN, Arrais PSD, Luiza VL, Pizzol TSD. Acesso e uso de medicamentos para hipertensão arterial no Brasil. Rev Saude Publ 2016; 50(2):8s.
  • 6
    Barreto M, Cesse E, Lima R, Marinho M, Specht Y, Carvalho E, A Fontbonne. Análise do acesso ao tratamento medicamentoso para hipertensão e diabetes na Estratégia de Saúde da Família no Estado de Pernambuco, Brasil. Rev Bra. Epidemiol 2015; 18(2):413-424.
  • 7
    Neri AL, Yassuda MS, Araújo LF, Eulálio MC, Cabral BE, Siqueira MEC, Santos GA, Moura JGA. Metodologia e perfil sociodemográfico, cognitivo e de fragilidade de idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Cad Saude Publica 2013; 29(4):778-792.
  • 8
    Instituto Brasileiro de Geografia e Estatística (IBGE). [acessado 2017 jul 14]. Disponível em http://www.ibge.gov.br
    » http://www.ibge.gov.br
  • 9
    Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA, Cardiovascular Health Study Collaborative Research Group. Frailty in older adults evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56(3):146-157.
  • 10
    Ferrucci L, Guralnik JM, Studenski S, Fried LP, Cutler GB, Walston JD. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc 2004; 52(4):625-634.
  • 11
    Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12(3):189-198.
  • 12
    Brucki SM, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr 2003; 61(3):777-781.
  • 13
    Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. Jama 1963; 185(12):914-919.
  • 14
    Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Nursing Research 1970; 19(3):278.
  • 15
    Malachias MVB, Póvoa RMS, Nogueira AR, Souza D, Costa LS, Magalhães ME. 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 2 - Diagnóstico e Classificação. Arq Bras Cardiol 2016; 107(Supl. 3):7-13.
  • 16
    Zattar LC, Boing AF, Giehl MWC, d'Orsi E. Prevalência e fatores associados à pressão arterial elevada, seu conhecimento e tratamento em idosos no sul do Brasil. Cad Saude Publica 2013; 29(3):507-521.
  • 17
    Bezerra VM, Andrade ACS, César CC, Caiaffa WT. Desconhecimento da hipertensão arterial e seus determinantes em quilombolas do sudoeste da Bahia, Brasil. Cien Saude Colet 2015; 20(3):797-807.
  • 18
    Gee ME, Bienek A, McAlister FA, Robitaille C, Joffres M, Tremblay MS, Johansen H, Campbell NR. Factors associated with lack of awareness and uncontrolled high blood pressure among Canadian adults with hypertension. Can J Cardiol 2012; 28(3):375-382.
  • 19
    Valle TGM, Melchiori LE, organizadores. Saúde e desenvolvimento humano. São Paulo: Editora UNESP; 2010.
  • 20
    Costa-Júnior FM, Couto MT, Maia ACB. Gênero e cuidados em saúde: Concepções de profissionais que atuam no contexto ambulatorial e hospitalar. Sexualidad, Salud y Sociedad 2016; (23):97-117.
  • 21
    Hu Y, Wang Z, Wang Y, Wang L, Han W, Tang Y,Xue F. Hou L, Liang S, Zhang Biao, Wang W, Asaiti K, Pang H, Zhang M, Jiang J. Prevalence, Awareness, Treatment, and Control of Hypertension among Kazakhs with high Salt Intake in Xinjiang, China: A Community-based Cross-sectional Study. Sci Rep 2017; 7:45547.
  • 22
    Nunes BP, Soares MU, Wachs LS, Volz PM, Saes MO, Duro SMS, Thumé E, Facchini LA. Hospitalization in older adults: association with multimorbidity, primary health care and private health plan. Rev Saude Publica 2017; 51:43.
  • 23
    Blay SL, Fillenbaum GG, Andreoli SB, Gastal FL. Equity of access to outpatient care and hospitalization among older community residents in Brazil. Med Care 2008; 46(9):930-937.
  • 24
    Wang HH, Wang JJ, Lawson KD, Wong SY, Wong MC, Li FJ, Wang PX, Zhou ZH, Zhu CY, Yeong YQ, Griffiths SM, Mercer SW. Relationships of multimorbidity and income with hospital admissions in 3 health care systems. Ann Fam Med 2015; 13(2):164-167.
  • 25
    Esperandio EM, Espinosa MM, Martins MSA, Guimarães LV, Lopes MAL, Scala LCN. Prevalência e fatores associados à hipertensão arterial em idosos de municípios da Amazônia Legal, MT. Rev. Bras. Geriatr Gerontol 2013; 16(3):481-493.
  • 26
    Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos Indicadores Sociais Rio de Janeiro; 2015.
  • 27
    Soares SI, Dominguez UMA, Porto SM. O mix público-privado no Sistema de Saúde Brasileiro: financiamento, oferta e utilização de serviços de saúde. Cien Saude Colet 2008; 13(5):1431-1440.
  • 28
    Mendes EV. 25 anos do Sistema Único de Saúde: resultados e desafios. Estud. Av 2013; 27(78):27-34.
  • 29
    Souza GCA, Costa ICC. O SUS nos seus 20 anos: reflexões num contexto de mudanças. Saude Soc 2010; 19(3):509-517.
  • 30
    Telesi Júnior E. Práticas integrativas e complementares em saúde, uma nova eficácia para o SUS. Estud Av 2016; 30(86):99-112.
  • 31
    Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cien Saude Colet 2012; 17(11):2865-2875.
  • 32
    Viegas APB, Carmo RF, Luz ZMP. Fatores que influenciam o acesso aos serviços de saúde na visão de profissionais e usuários de uma unidade básica de referência. Saude Soc 2015; 24(1):100-112.
  • 33
    Buss PM, Pellegrini Filho A. Iniqüidades em saúde no Brasil, nossa mais grave doença: comentários sobre o documento de referência e os trabalhos da Comissão Nacional sobre Determinantes Sociais da Saúde. Cad Saude Publica 2006; 22(9):2005-2008.
  • 34
    Almeida AR, Athayde FTS. Promoção da saúde, qualidade de vida e iniquidade em saúde: reflexões para a saúde pública. Tempus Actas de Saude Coletiva 2016; 9(2):165-172.
  • 35
    Instituto Brasileiro de Geografia e Estatística (IBGE). Síntese dos Indicadores Sociais Rio de Janeiro: IBGE; 2013.
  • 36
    Santos GA, Vaz CE. Grupos da terceira idade, interação e participação social. In: Zanella AV, Siqueira MJT, Lhullier LA, Molon SI, organizadoras. Psicologia e práticas sociais [online]. 2008 [acessado 2017 jul 14]. Disponível em: http://books.scielo.org/id/886qz/pdf/zanella-9788599662878-31.pdf
    » http://books.scielo.org/id/886qz/pdf/zanella-9788599662878-31.pdf

Publication Dates

  • Publication in this collection
    26 Sept 2019
  • Date of issue
    Oct 2019

History

  • Received
    23 July 2017
  • Accepted
    02 Feb 2018
  • Published
    04 Feb 2018
ABRASCO - Associação Brasileira de Saúde Coletiva Av. Brasil, 4036 - sala 700 Manguinhos, 21040-361 Rio de Janeiro RJ - Brazil, Tel.: +55 21 3882-9153 / 3882-9151 - Rio de Janeiro - RJ - Brazil
E-mail: cienciasaudecoletiva@fiocruz.br