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Introduction
Aging brings physiological changes, including loss of elasticity in blood vessels, leading to arterial stiffening and increased ventricular contractility. This, in turn, can increase systemic blood pressure, contributing to the development of systemic arterial hypertension (SAH). 1,2 SAH has been recognized as a predictor of poor prognosis in various health conditions, affecting target organs such as the heart, brain, kidneys, and arterial system. 3 The prevalence of SAH increases significantly with age, with a substantial proportion of older individuals being affected. For example, globally, it is estimated that about 60 % of older individuals aged 60-69 suffer from SAH, and this proportion increases even more at older ages. 4 In Brazil, the prevalence of SAH among older adults ranges from 46.9 % to 62.1 %, with a tendency to be higher in women and at more advanced ages. However, local studies show that this prevalence can be even higher in certain areas, reaching nearly 75 % among those over 60. 5
In addition to its direct effects on cardiovascular health, SAH is intrinsically linked to aging-related complications such as gait changes, frailty, and an increased risk of falls in older adults. Antihypertensive medication treatment, although essential for blood pressure control, can paradoxically increase the risk of falls due to orthostatic hypotension, especially in older adults. This increased risk of falls can negatively impact these individuals' quality of life and independence. 5,6,7
Considering the relationship between SAH and the fear of falling in older adults, it is essential to highlight that the fear of falling is a significant concern in this age group. The perception of fall risk can reduce physical activity and mobility, contributing to the cycle of frailty and decreased quality of life. 8,9 Furthermore, individuals with SAH tend to report a greater fear of falling, possibly due to the association between this condition and the occurrence of adverse events such as fainting and dizziness. 10 Therefore, understanding this interaction between SAH and the fear of falling is crucial for developing effective fall prevention and health promotion strategies for older adults.
In addition to the factors mentioned, the prevalence of SAH in older adults is also associated with sociodemographic and health aspects. For example, it is more prevalent among individuals with low education, lower socioeconomic status, and low-prestige occupations. 10 Moreover, the presence of other health conditions, such as obesity, diabetes mellitus, and chronic kidney disease, significantly increases the risk of developing SAH in older adults. 11 A sedentary lifestyle and excessive alcohol consumption are also significant risk factors for developing SAH in this age group. 12
These data underscore the importance of prevention and control strategies for SAH, considering not only clinical factors but also sociodemographic and behavioral aspects. Given the high prevalence and significant impacts of SAH on the health of the older population and its relationship with fall risk and fear of falling, more studies are needed to better understand these variables that influence the prognosis. Thus, this study aimed to investigate the association between sociodemographic, health, and risk variables and fear of falling with the presence of SAH in older people.
Methodology
This is a quantitative, observational, cross-sectional, and analytical study approved by the Research Ethics Committee of Cesumar University (Unicesumar), under number 6.301.362 (CAAE: 73641723.7.0000.5539), based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).
A non-probabilistic, convenience sample was intentionally selected, comprising 110 older adults (aged 60 years or older), of both sexes, who were users of a Medical Specialty Center in the municipality of Sapezal, state of Mato Grosso, Brazil. Among them, 70 were diagnosed with SAH and were on antihypertensive medication, while 40 had no diagnosis of SAH. The diagnosis of hypertension and the use of antihypertensive drugs were confirmed through electronic medical records available at the health facility.
To be included in the study, participants had to be registered in the municipality’s health database and followed by both a cardiologist and an orthopedist. Exclusion criteria were: use of benzodiazepines (due to their central nervous system depressant effects, such as anticonvulsant, sedative, muscle relaxant, and anxiolytic actions); the presence of osteoarticular diseases or injuries that could hinder performance during physical testing; and previously documented cognitive impairments that would compromise the reliability of questionnaire responses. It is important to note that cognitive status was not directly assessed through formal scales during data collection. Instead, the presence or absence of cognitive deficits was verified using information already available in the patients’ electronic medical records.
A formal sample size calculation was not conducted, as the total number of older adults registered in the health center’s system was not clearly defined or accessible at the time of the study. Given these constraints, the convenience sampling approach was adopted. We acknowledge that this method may introduce a selection bias, which may limit the external validity and generalizability of the results. This limitation is addressed in the discussion section.
To evaluate the sociodemographic and health profile of older adults, a semi-structured questionnaire was developed by the authors specifically for this study. The instrument was designed to collect descriptive information and did not undergo a formal validation process, as it aimed solely to gather objective data related to personal and clinical characteristics. The questionnaire included questions on age, age group, sex, income in minimum wages, occupational status, retirement, education, marital status, use of antihypertensive medication, use of medicines in general, presence of comorbidities, history of falls, history of near falls, and class of antihypertensive used.
The risk of falls was assessed using the Timed Up and Go (TUG) test, which involves the older person rising from a chair, walking three meters, and returning to the chair. Individuals were only evaluated after familiarizing themselves with the course. A predictive value of ≥ 12.47 seconds was used for high fall risk and ≤ 12.47 seconds for low fall risk.13
The fear of falling was assessed using the Falls Efficacy Scale-International (FES-I), in its version validated for Brazil by Camargos et al. (14 This questionnaire consists of 16 items related to activities of daily living, in which individuals rate how concerned they are about falling while performing each task, using a 4-point Likert scale ranging from 1 (not at all concerned) to 4 (very concerned). The total score ranges from 16 to 64, with higher scores indicating a greater fear of falling. Standardized administration procedures were followed, including individual application by trained evaluators in a quiet setting, ensuring participants’ understanding of each item. Cut-off points were used to classify the results: < 23 indicates absence of fear of falling; ≥ 23 points indicates occasional fear of falling; and ≥ 31 points indicates recurrent fear of falling. 14
First, authorization was requested from the Central Regulation of the Municipal Health Secretariat of Sapezal-MT to conduct the research. Subsequently, the Central scheduled specialized Cardiology and Orthopedics consultations, referring patients to the Medical Specialty Center, where consultations are held on pre-scheduled days and times. This allowed contact with older individuals diagnosed with SAH (or not) and their respective medical records.
Those who agreed to participate in the research signed the Informed Consent Form, and the researcher herself collected data from September to November 2023.
The data were analyzed using SPSS software version 25.0. Descriptive and inferential statistics were employed. Frequencies and percentages were used as descriptive measures for categorical variables. The Chi-square test was used to compare the proportions of hypertensive and non-hypertensive older individuals with sociodemographic, health, fall risk, and fear of falling variables. Binary logistic regression (both crude and adjusted analysis) was used to examine the associations of sociodemographic, health, fall risk, and fear of falling variables (independent variables) with the presence of SAH (dependent variable). For the regression analysis modeling, only variables with a significance level equal to or less than 0.05 for association with the presence of SAH in the Chi-square test were considered. The model fit was verified using the Hosmer-Lemeshow test. A significance level of p < 0.05 was considered.
Although SAH is a chronic condition that precedes functional outcomes such as falls or fear of falling, in this study it was used as the dependent variable in exploratory logistic regression analysis. The aim was not to infer causality, but rather to identify functional and clinical characteristics statistically associated with the presence of SAH in this population. This approach enables a better understanding of the health profile of hypertensive older adults and helps identify relevant associations for clinical screening and prevention strategies.
Results
In comparing the proportions of hypertensive and non-hypertensive older individuals based on sociodemographic variables (Table 1), a significant difference was found between the groups only in occupational status (p = 0.047). This difference indicates a higher proportion of older individuals who do not have an active occupational status and are hypertensive.
Table 1: Comparison of proportions of hypertensive and non-hypertensive older individuals based on sociodemographic variables, Sapezal, Brazil, 2023
*Significant association - p < 0.05: Chi-square test or Fisher's Exact Test. SM: minimum wage(s). MW: minimum wages.
Table 2 . compares the proportions of hypertensive and non-hypertensive older individuals based on health variables. Significant differences were found between the groups regarding health perception (p < 0.001), medication use (p < 0.001), history of falls (p= 0.004) and near falls (p < 0.001), use of walking devices (p = 0.047), heart disease (p< 0.001), and diabetes (p = 0.007). There is a higher proportion of older individuals with poor health perception, using more than four medications, with a history of falls and near falls, using walking devices, having or having had heart disease, and with diabetes who are hypertensive.
Table 2: Comparison of proportions of hypertensive and non-hypertensive older individuals based on health variables, Sapezal, Brazil, 2023
*Significant association - p < 0.05: Chi-square test or Fisher's Exact Test. CVA: Cerebrovascular Accident.
According to the data in Table 3, a significant difference was observed when comparing the proportions of hypertensive and non-hypertensive older individuals based on fall risk (p < 0.001) and fear of falling (p < 0.001), indicating a higher proportion of older individuals with fall risk and fear of falling associated with recurrent falls who are hypertensive.
Table 3: Comparison of proportions of hypertensive and non-hypertensive older individuals based on fall risk and fear of falling, Sapezal, Brazil, 2023
*Significant association - p < 0.05: Chi-square test or Fisher's Exact Test.
For the logistic regression analysis, only the variables that showed a significance level <0.05 in the Chi-square test with the presence of SAH were considered (Table 4).
Table 4: Factors associated with hypertension, Sapezal, Brazil, 2023
*Significant association - p < 0.05: Binary Logistic Regression. Adjusted OR for all variables. OR: Odds Ratio; CI: Confidence Interval.
In the crude analysis, the following factors individually showed significant association (p < 0.05) with SAH: occupational status, health perception, medication use, history of falls and near falls, fall risk, and fear of falling. According to the data in Table 4, the crude logistic regression analysis showed that several variables were significantly associated (p < 0.05) with the presence of SAH, including occupational status, health perception, medication use, history of falls and near falls, fall risk, and fear of falling. In the adjusted model, only medication use and fear of falling remained significantly associated with the presence of SAH.
It is important to emphasize that this association does not imply a causal relationship. The finding likely reflects the greater clinical complexity of hypertensive older adults, who tend to present with multiple comorbidities and, consequently, a higher number of prescribed medications. Similarly, fear of falling -particularly when associated with sporadic falls- was also independently associated with hypertension, with these individuals being 9.036 times more likely (95 % CI = 1.003-87.472) to have SAH compared to those reporting fear of falling without associated falls.
Discussion
The results of the present study revealed that older individuals who use a greater quantity of medications (in general, not just antihypertensives) are more likely to have SAH. Older individuals who fear falling associated with sporadic falls are also more likely to have SAH. Hypertensive older individuals are those with a higher proportion of individuals who have inactive occupational status, perceive their health as poor, have a history of falls and near-falls, use walking aids, have or have had heart disease and diabetes, and are at risk of falls or fear falling.
The fact that older individuals who use three to four medications are more likely to have SAH compared to those using one to two medications can be explained by these individuals generally facing greater complexity in their medication regimen. With multiple medications, there is a higher likelihood of forgetting or needing clarification about the correct administration of doses. This can lead to missed doses or improper administration, which can negatively affect blood pressure control, as Barroso et al. 15 noted. Furthermore, as Morais et al. 16 and Viana 17 suggest, the more medications prescribed, the greater the potential for drug interactions among them. These interactions can decrease the effectiveness of antihypertensive medications, making blood pressure control more challenging.
It is important to emphasize that the observed association between the number of medications used and the presence of SAH should not be interpreted as causal. Rather than suggesting that polypharmacy leads to SAH, this association likely reflects the greater clinical complexity of hypertensive individuals, who typically have multiple comorbidities requiring pharmacological management. The presence of SAH in these individuals is therefore more plausibly understood as part of a broader multimorbidity profile, in which higher medication use is a marker, not a cause. This interpretation aligns with current literature emphasizing the multifactorial nature of both hypertension and polypharmacy.
We found that older individuals with a fear of falling associated with sporadic falls are more likely to have SAH than those with a fear of falling without association with actual falls. This result may be because fear of falling can trigger a series of physiological responses, including chronic stress and anxiety, which in turn can contribute to an increase in blood pressure, especially in older adults whose stress regulation systems may be compromised due to aging. 18,19 Additionally, according to Nogueira et al., 20 fear of falling can lead to activity restriction and reduced mobility, thereby increasing the risk of developing or worsening SAH. As per the Alpsoy, 21 lack of regular physical activity can lead to weight gain, decreased cardiovascular fitness, and reduced effectiveness in blood pressure regulation.
In the present study, there was a higher proportion of older individuals who do not have active occupational status and are hypertensive. This can be justified because older individuals no longer actively engaged in occupational activities tend to lead a more sedentary lifestyle. As previously noted, lack of regular physical activity is associated with an increased risk of SAH, as physical activity helps to control blood pressure and maintain cardiovascular health. Additionally, the absence of occupation can lead to emotional stress and social isolation in some older individuals. Chronic stress can elevate blood pressure, while social isolation can have adverse effects on mental health, both indirectly contributing to SAH. 22
We observed a higher proportion of older individuals who perceive their health as poor and hypertensive. This can be explained by the fact that older individuals who perceive their health as poor often deal with multiple medical conditions, including SAH, which frequently coexists with other chronic diseases such as diabetes, heart and kidney diseases. According to Rodrigues et al., 23 this accumulation of medical conditions can contribute to a negative perception of health. Moreover, SAH can significantly impact the quality of life, causing symptoms such as fatigue, headaches, dizziness, and difficulty concentrating. These symptoms can influence the health perception of older individuals, especially if they are not receiving adequate treatment or are facing challenges in blood pressure control. 5 Uncontrolled SAH can also lead to severe complications such as stroke and heart disease, which in turn can result in functional limitations and reduced ability to perform daily activities. 15 These limitations can negatively affect the health perception of older individuals, particularly if they are experiencing mobility difficulties or loss of autonomy.
We found a higher proportion of older individuals with a history of falls and near falls who are hypertensive, which can be explained by several factors. Firstly, SAH is often associated with medical conditions that increase the risk of falls, such as cardiovascular diseases, diabetes, and cognitive impairment. 24 Additionally, certain antihypertensive medications can cause side effects such as dizziness and weakness, which increase the risk of falls, especially in older adults. 15,25
Another aspect to consider is that SAH can contribute to the deterioration of vascular health, including blood vessel health in the brain. This can increase the risk of cerebrovascular events, such as strokes, which in turn can predispose older individuals to falls. 26 It is worth noting that SAH may be associated with balance and mobility problems, which are significant risk factors for falls in older adults. 27
We also observed a higher proportion of older individuals who use walking aids and are hypertensive. Older individuals who require walking aids often face physical health challenges such as muscle weakness, joint pain, or balance issues, which may be related to chronic conditions, including SAH. Furthermore, SAH can contribute to the deterioration of vascular health, including blood vessel health in the brain. 26 This can increase the risk of cerebrovascular events, such as strokes, affecting mobility, and the need for walking assistance devices.
It is also worth noting that SAH is associated with a range of medical conditions that can increase the risk of mobility impairment, such as heart disease, diabetes, and cognitive impairment. These conditions may require walking aids to ensure safety and stability during mobility. 28
In the present study, we found that a higher proportion of older individuals who have or have had heart disease and diabetes are hypertensive. Several interconnected factors can explain this finding. Firstly, SAH is closely linked to cardiovascular diseases such as coronary heart disease, heart failure, and arrhythmias. These cardiac conditions can elevate blood pressure due to impaired cardiac and vascular function. 29 Similarly, diabetes, especially when poorly controlled, can lead to cardiovascular complications such as atherosclerosis (narrowing of arteries due to plaque buildup), which increases the risk of SAH. 26 Insulin resistance, common in type 2 diabetes, can also contribute to the development of SAH. 30 Furthermore, both heart disease and diabetes involve a range of shared risk factors with SAH, such as obesity, sedentary lifestyle, poor diet, and family history. 14
A higher proportion of older individuals with fall risk and fear of falling, mainly when associated with recurrent falls, were also found to be hypertensive. This finding can be attributed to several interconnected factors. SAH can contribute to the deterioration of vascular health, including blood vessel health in the brain. This can increase the risk of cerebrovascular events such as strokes, affecting mobility and increasing the risk of falls in older adults. 25 Additionally, certain antihypertensive medications can cause side effects such as dizziness and weakness, which may increase the risk of falls, especially in older individuals with fragile health conditions. 15,25
Fear of falling associated with recurrent falls can lead to a cycle of fear, anxiety, and activity restriction, which in turn can further reduce mobility and increase the risk of falls. This anxiety and fear may be exacerbated in hypertensive older individuals due to concerns about health and the potentially severe consequences of falls. 18
Despite the relevant findings, this study presents limitations that must be acknowledged. First, the use of a non-probabilistic, convenience sample without prior sample size calculation-due to the unavailability of accurate data on the total number of older adults registered at the health center-introduces a potential selection bias. This limitation compromises the representativeness of the sample and restricts the generalizability of the results to broader populations.
Second, the study is subject to memory bias, as the collection of sociodemographic information, health status, and fear of falling relied on participants’ self-report. Such data may be imprecise or influenced by subjective perceptions, potentially affecting the accuracy of the findings.
Third, although logistic regression was used to adjust for confounding factors, there may have been limited control over other important variables that could influence the associations studied. Some relevant variables may not have been included or fully captured, which could impact the robustness of the statistical modeling.
Additionally, it is important to clarify that SAH, although a chronic biological condition that typically precedes functional decline, was used in this study as the dependent variable in an exploratory logistic regression model. This analytical choice does not aim to establish causality, but rather to describe the functional and clinical characteristics associated with the presence of SAH in this specific population. The approach allowed for the identification of potential markers related to health vulnerability in hypertensive older adults. However, the limitations of interpreting reverse causality in this context must be acknowledged.
Finally, the complex interactions between SAH, fall risk, and fear of falling may not have been fully explored in this study. These phenomena are multifactorial and can be influenced by a range of clinical, psychological, social, and environmental factors not addressed in the present analysis.
Conclusion
The findings of this study underscore significant associations between multiple sociodemographic, health, and behavioral factors and the presence of SAH in older individuals. Fear of falling associated with sporadic falls, inactive occupational status, poor self-perceived health, history of falls and near falls, use of walking aids, presence of heart disease and diabetes, as well as increased fall risk and fear of falling, were more prevalent among hypertensive older adults.
These results reflect the complexity and interconnectedness of factors that may coexist with SAH in this population. Although causality cannot be inferred, the identification of these associations may help guide multidisciplinary approaches focused on screening, monitoring, and support for older adults with SAH.
