Functional performance indicators associated with hypertension in older people

Abstract Introduction During aging, changes occur in the human body that increase the probability of arterial hypertension which can potentiate deleterious effects on functional performance. Objective To analyze the association of functional performance indicators with hypertension in older people. Methods An epidemiological, population-based, cross-sectional survey was conducted with 209 older adults (58.40% women). Functional performance was assessed by the following tests: handgrip strength; chair stand test; arm curl test; timed up and go (TUG); sit and reach test; and step in place test (SPT). Diagnosis of arterial hypertension was self-reported. Results The prevalence of hypertension was found to be 58.90% (males: 51.70%; females: 63.90%). It was also observed that the hypertensive individuals of both sexes had worse performance in SPT and TUG (p < 0.05). Furthermore, it was found that each additional second for TUG increased by 11% the probability of hypertension in men (PR:1.11; 95%CI: 1.03-1.20) and by 7% in women (PR: 1.07; 95%CI: 1.04-1.12), while each step performed in the SPT decreased the probability for the outcome by 2% (men and women = PR: 0.98; 95%CI: 0.97-0.99). Conclusion TUG was found to be positively associated with hypertension, while SPT was inversely associated with hypertension.


Introduction
Arterial hypertension is a chronic non-transmissible disease and is one of the most important risk factors for the onset of cardiovascular diseases.It has a multifactorial etiology which in turn is influenced by genetic/epigenetic, environmental, cultural, social and lifestyle factors, and it is characterized by high and sustained blood pressure levels. 1 The frequency of this morbidity tends to increase with advancing age, which makes it more prevalent in older people.According to data from the Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey, the age group between 55 and 64 years has a prevalence of hypertension of 49.40%, and in older adults 65 years or more, the prevalence is on the order of 61%. 2 With regard to its evolution, it often presents as an asymptomatic condition and can lead to structural and/or functional changes in target organs, such as the heart, brain and kidneys. 1 Thus, regardless of its etiology, hypertension has the potential to culminate in complications, such as acute myocardial infarction, stroke, chronic kidney disease and a higher risk of mortality.1 In addition, it is worth noting that the referred morbidity is a risk factor for cognitive decline, dementia and loss of functionality, especially in older people.3 In this context, it appears that, chronically, hypertension appears to have an adverse effect on functional performance, which can promote its decline with aging and negatively impact the functional independence of the older adults.and a bedridden condition.
To this end, a census was initially carried out to identify all older adult's residents in the Aiquara headquarters, with the help of community health agents working in the ESF, which covers 100% of the municipality's population.
Thus, all households in the urban area were visited and 232 older people met the established criteria.9 Among these, for the present study, 23 were excluded for not having performed even one of the functional performance tests.

Collection of data
Data collection took place in two stages: To standardize the collection of information, prior to collection, training was carried out for the responsible team through theoretical and practical workshops.
Subsequently, from December 2012 to January 2013, a pilot study was conducted in a neighboring municipality of Aiquara, to determine the time required for the interview.In addition, the aim was to resolve possible doubts regarding the completion and adequacy of the form used for data collection.

Anthropometry
Body mass was measured using a portable digital balance (Plenna®).For this purpose, the older people stood barefoot with their arms resting at their side, wearing light clothes and looking straight ahead.Height was measured using a portable stadiometer (WiSO®).
The participants were barefoot, with their feet together, heels, buttocks and shoulder girdle against the wall and in an upright position, looking straight ahead.10 This information was used to calculate the body mass index Functional performance (predictors) Functional performance was assessed using handgrip strength (HGS) 12 and the Senior Fitness Test battery.13 HGS was measured using a hydraulic dynamometer (Saehan Corporation SH5002, 973, Yangdeok-Dong, MasanHoewon-Gu, Changwon 630-728, South Korea), adjusted according to the older person's hand size, so that the first and second finger joints were flexed.The measurement was performed on the dominant arm, with the person sitting, arms close to the body, elbow flexed at 90° and forearm in a neutral position.12 During the measurement, incentives were given so that the handle of the dynamometer was squeezed as hard as possible.
This test was performed twice, with a one-minute interval, and the higher value identified in kilogram-force (kgf) was used for the analyses.10 The Senior Fitness Test battery was conducted as described in Chart 1.
The evaluators demonstrated the tests to the older adults before their application.Thus, to facilitate the understanding of the movements, the participants performed the tests previously.The final execution of the test, which was recorded, was performed twice with an interval of two minutes.For analysis purposes, the value of the best performance in the tests was taken.Chart 1 -Objectives, instruments and procedures adopted for the application of the Senior Fitness Test battery in the study population

Chair stand test
The chair stand test aims to measure the strength and resistance of the lower limbs.It was carried out using a stopwatch and a chair with a backrest (without arms) with a seat height of approximately 43 cm.The execution consisted in sitting down and standing up as many times as possible in 30 seconds.
Arm curl test Arm curl test measures the strength and resistance of the upper limbs.In this test, a stopwatch, a chair with a backrest (without arms) and dumbbells (2.0 kg for women and 4.0 kg for men) were used.The test consisted in flexing the dominant arm as many times as possible, starting from a neutral position to a complete supine position in a period of 30 seconds.

Timed up and go
The timed up go test aims to assess mobility, agility and dynamic balance.For this purpose, a chair with a backrest (without arms) at a height of approximately 43 cm, a stopwatch, a measuring tape and a cone were used.At the evaluator's command, the participant got up from the chair (they could push their thighs or the chair), walked as fast as possible for 1.22 m, walked around a cone, returned to the chair and sat down.The time in seconds for performing the test was recorded.

Sit and reach test
The sit and reach the feet test assesses the flexibility of the lower limbs and hamstring muscles.For its execution, a ruler of 45 cm was used and a chair without arms, with a backrest at a height of approximately 43 cm to the seat.For this, the participant started with the dominant leg extended, spine erect, head aligned with the spine and hand over hand.Thus, gradually, the older person tried to touch their toes, without flexing the knee.After the older adults reached their maximum points, the distance was measured with the ruler.The distance (cm) observed before reaching the fingertips was registered in a negative way (-) and that reached beyond, in a positive way (+).
Step in place test The step in place test (stationary walking) was used to measure aerobic resistance.It counted the maximum number of knee lifts that the older people were able to perform in two minutes (without running).The minimum knee height, appropriate in the stride, was leveled at a midpoint between the patella and the anterior superior iliac spine.

Arterial hypertension (outcome)
The outcome analyzed was ascertained through the previous diagnosis, self-reported by the older adults, based on the following question: "Has any doctor ever said that you have hypertension, that is, that you have high blood pressure?".Thus, according to the response, this variable was categorized in a dichotomous way (hypertension: yes or no)..

Adjustment variables
With the purpose of adjustments, the following

Results
The epidemiological investigation was conducted with 209 older people.The mean ages of men and women were, respectively, 72.30 ± 8.13 and 71.05 ± 6.75 years.Furthermore, the characteristics of the study population were as follows: 58.40% were women; 84.70% had no education; 86.70% reported income less than or equal to the minimum wage; 51.70% were classified as insufficiently active; and 58.90% were hypertensive (men: 51.70%; women: 63.90%).Other features of the study population can be seen in Table 1.

Discussion
The main results of this epidemiological investigation showed that hypertensive older people of both sexes showed worse performance in the TUG test and in the SPT.Furthermore, it was identified that the longer time spent for TUG increased the probability of hypertension, while a greater number of steps in the SPT attenuated the probability for the outcome in men and women.In view of these results, the aforementioned authors listed some hypotheses to explain this situation.
Among them, it appears that people with lower aerobic capacity tend to have a higher level of asymmetric dimethylarginine protein, which inhibits, for example, the This study had some limitations.Among them, there is the self-reported diagnosis for the analyzed outcome.
However, the use of MMSE is highlighted as an exclusion criterion for older people with cognitive impairment, to reduce the impact of memory bias.In addition, it should be noted that the results presented refer to the panorama verified during the data collection carried out in 2013, which may not reflect the current situation.

Conclusion
There was evidence that, in both sexes, hypertensive participants showed worse performance in the TUG test and in SPT.Furthermore, TUG was positively associated with hypertension, while SPT showed an inverse association.
The results of the present study, therefore, show that hypertensive older individuals had less agility, balance, ability to walk and cardiorespiratory resistance when compared to non-hypertensive individuals.Faced with these findings, there is a need to adopt measures aimed at preventing hypertension and minimizing its possible adverse effect on the functional performance of the older adults.Among the possible non-pharmacological

FISIOTERAPIA
EM MOVIMENTO Physical Therapy Santos ES et al.Fisioter Mov.2023;36:e36113 8 strategies, we highlight physical exercises of an aerobic nature and also counter-resistance exercises.recentposition on the subject, began to recommend that people with hypertension perform two or more days of resistance training, weekly, on non-consecutive days, consisting of eight to ten exercises, with a margin of eight to twelve repetitions, which must be performed at an intensity that generates considerable muscle fatigue.25 However, the originality of the present study stands out as a strong point, since it was the first Brazilian population survey to analyze the association of functional performance indicators with hypertension, focusing on the older population of a small municipality, in the Northeast region of the country, which has low socioeconomic indicators and difficulties in providing health services.14Therefore, it is believed that the evidence presented can be of health for the measures taken by health professionals working in the scope of primary health care promoting interventions aimed at improving or maintaining good levels of physical fitness in the older adults, both for the prevention of hypertension and to mitigate its potential deleterious impact on functional performance in these people, especially regarding the ability to walk and cardiorespiratory resistance.
normality distribution of the data was verified by sex, using the Komolgorov Smirnov test.For comparisons, Student's t-test was used for normal distributions and the Mann-Whitney U test for non-normal distributions.
19cohol use (yes or no); self-reported diagnosis of diabetes mellitus (yes or no); self-perceived health (excellent/very good/good or fair/poor); occurrence of falls in the last twelve months before collection (yes or no); and nutritional status (underweight: BMI < 22.19Statistical analysisThe descriptive analysis of the population's characteristics was conducted by calculating relative and absolute frequencies, means, medians, standard deviations and interquartile ranges, in addition to the response percentage for each analyzed variable.The FISIOTERAPIA EM MOVIMENTO Physical Therapy in Movement Santos ES et al.Fisioter Mov.2023;36:e36113 5

Table 2 -
Comparison of height, weight and body mass index (BMI) among older persons of both sexes and with and without hypertension

Table 3 -
Comparison of functional performance indicators between older persons of both sexes, with and without hypertension Note: % = percentage of responses; NH = non-hypertensives; H = hypertensives; HGS = handgrip strength; CST = chair stand test; ACT = arm curl test; TUG = timed up and go; SRT = sit and reach test; SPT = step in place test; kgf = kilogram-force; tsu = times stood up; s = seconds.@ Mean and standard deviation; # Median and interquartile interval.Values in bold indicate p < 0.05.

Table 4 -
Association between functional performance indicators and hypertension in older people, according to sex SPT = step in place test; kgf = kilogram-force; tsu = times stood up; s = seconds.a Adjusted by nutritional status and history of falls; b Adjusted by nutritional status, history of falls and diabetes mellitus; c Adjusted by nutritional status; d Adjusted by nutritional status and physical activity level.Values in bold indicate p < 0.05.EM MOVIMENTO Physical Therapy in Movement Santos ES et al.