Journal of Human Hypertension (1998) 12, 539–545
 1998 Stockton Press. All rights reserved 0950-9240/98 $12.00
http://www.stockton-press.co.uk/jhh
ORIGINAL ARTICLE
Hypertension in the elderly: attitudes of
British patients and general practitioners
M Cranney, E Warren and T Walley
Prescribing Research Group, Department of Pharmacology & Therapeutics, University of Liverpool, 70
Pembroke Place, Liverpool L69 3BX, UK
The perceptions of patients and GPs of the risk of stroke
in treated and untreated elderly hypertensives, and their
attitudes towards anti-hypertensive therapy were examined. To explore attitudes of patients to the management
of hypertension a qualitative approach was used,
employing semi-structured interviews, with subsequent
thematic analysis of the transcriptions. A questionnaire
study of GPs’ attitudes to the same subject was also
conducted.
The elderly (n ⴝ 75) greatly overestimate the risks of
hypertension and the benefits of treatment. Most would
accept anti-hypertensive therapy despite being informed of the true risks, citing confidence in their doctor
as the major determinant in their decision. GPs
(n ⴝ 121) were well informed of the risks and benefits,
but less than half adhere to current guidelines.
GPs should be aware how much the elderly overestimate the risks of hypertension and the benefits of its treatment. When considering treating hypertension in this
group, patient contributions in the treatment decisionmaking process should be actively encouraged, especially
as many elderly hold a deferential attitude towards their
doctor. Patients should be informed of the risks of their
disease and the benefits of treatment in terms they understand. The use of visual aids helps patients to grasp the
difficult concepts of risk and benefit.
Keywords: hypertension; elderly; general practitioners; attitudes; primary care
Introduction
Treating hypertension in the elderly prevents
strokes and heart attacks.1–3 Guidelines have been
produced to facilitate the implementation of this
message.4 Unfortunately many studies show that
this condition is currently not well managed in British general practice.5 Effectively, guidelines are frequently ignored despite strong, consistent and convincing evidence that treating healthy elderly
patients with hypertension can prevent disabling
consequences of coronary and cerebrovascular disease.2
Although the benefits to populations of patients
are well defined by the existing evidence, patients
and GPs may be more influenced in their decisions
to accept treatment or to treat respectively by the
benefits of treatment to the individual patient. General practitioners and patients have moved towards
sharing medical decisions.6 The patient brings
knowledge of their own subjective aims and values,
while the GP brings knowledge of the risks and
benefits of various treatment options, both parties
contributing to an effective consultation.7,8 This
requires that doctors themselves are well informed
of the risks and benefits, and communicate these to
the patient. A recent report9 has identified that discrepancies between the doctor’s and the patient’s
perception of risk may be a significant factor in non-
Correspondence: Mike Cranney, 17 Villiers Crescent, Eccleston,
Merseyside WA10 5HP, UK
Received 6 March 1998; revised and accepted 23 April 1998
compliance. However, there has been little research
done in this important area and it is uncertain what
influence accurate information has on the patient’s
decision to accept treatment.
To identify some of the barriers preventing
implementation of guidelines for the management of
hypertension we explored how the well elderly and
GPs perceived the risks of stroke in untreated hypertension and the benefits of treatment, and whether
knowledge of the true risks and benefits altered their
attitudes to treatment.
Patients and methods
The study involved two groups, patients and GPs.
The elderly subjects of this study were healthy
patients between the ages of 65 and 79 (defined as
those who had not received any medication in the
previous 12 months). They were all drawn from the
practice of one of the authors (MC), this practice is
situated in a suburb of Liverpool and comprises predominantly social class three and four patients, it
has a higher than average elderly population with
19.5% ⬎65 years; 9.5% ⬎75 years and 5% ⬎80
years. All patients in the specified age range were
invited to participate. The invitation to participate
was made by letter and sent on university headed
notepaper. A research assistant at the university
who was unknown to the patients of the practice
signed the letter and a stamped addressed envelope
was enclosed to facilitate reply. A second and third
letter was devised in the event of a poor response.
A target of 60–80 patients was aimed for. Patients
Hypertension in the elderly: attitudes of patients and GPs
M Cranney et al
540
were asked for their co-operation with research into
the views of patients towards blood pressure and its
treatment and were asked if they were prepared to
allow a research assistant from Liverpool University
to visit them at home.
The GP subjects were attending two, week long,
‘refresher’ courses in April 1996. The demographic
characteristics of the participating GPs are summarised in Table 1.
Two similar questionnaires were devised, after
piloting, to explore the pre-existing understanding
and attitudes of the elderly and GPs towards hypertension (Appendix 1); opinions were sought from
the elderly and the GPs before and after seeing the
actual risks and benefits as defined by a major trial.
We presented data and sought responses in terms of
absolute risk, ie, strokes prevented per 100 patients
treated. The patients’ questionnaire was administered by two trained research assistants using semistructured interviews in the patients’ home. All of
the interviews were audiotaped and transcribed.
The GPs completed their written questionnaires
individually under supervision.
The pilot stages had revealed how difficult it was
to explore patients’ perceptions of risk. We therefore
piloted several potential visual aids before deciding
on that illustrated in Appendix 1, which was found
the most understandable by the patients. These were
then used with the questionnaire to explore the concept of risk and other factors that might influence
decisions to accept treatment. Some open-ended
questions were used so as not to limit the scope of
the patients’ answers.10
In providing a rigorous procedure for the analysis
of the qualitative data, two of the authors (MC and
EW) independently conducted thematic analysis of
the patients’ responses using an agreed coding
framework. The results of the separate analyses were
found to be concordant, thus establishing interrater reliability.11
In view of the qualitative nature of these findings,
we report emergent themes and support them with
some examples of direct quotations from patients.
To determine whether GPs adhered to currently
accepted guidelines, the GPs were also asked about
their management of a hypothetical patient who, by
any of these guidelines, should have received drug
treatment (see Appendix 1).
Table 1 Characteristics of GP respondents (n = 121)
Years since qualification:
Range: 6 to 43 years. Mean: 20
years. Median: 18 years.
Postgraduate qualifications:
None:
MRCGP:
Other Diploma:
Both of above:
47
39
35
27
Partner in a training practice:
Yes:
No:
40 (33%)
81 (66%)
Sex of GP:
Male:
Female:
90 (74%)
31 (26%)
Partnership status:
Single handed:
In a partnership:
15 (12%)
106 (88%)
(39%)
(32%)
(29%)
(22%)
Results
Of the 149 elderly invited to participate, 75 agreed
(age range: 66–92; mean age: 73). As the target number of patients had been achieved with the first invitation letter, no further invitations were sent. All of
the 121 GPs on the courses returned valid completed questionnaires.
Perceptions of risk and benefits
The perception of the elderly of the risk of stroke
was high with over 40% of untreated hypertensive
patients expected to have a stroke within 5 years.
Similarly, the elderly perceived the benefits of treatment to be correspondingly great, in thinking there
was more than a 50% relative reduction of stroke
risk. GPs were more accurate in their predictions,
giving an absolute risk of 11% and a relative
reduction of 50% (Figure 1). There was no correlation between number of years qualified and perception of risk.
Patients’ attitudes to treatment
Almost all the elderly initially said they would be
willing to take anti-hypertensive medication if prescribed by their doctor with only 3.9% being uncertain or declining treatment. However, after being
shown the actual risks and benefits, a quarter
became uncertain or would decline (Table 2). Five
main themes emerged from the patients’ initial statements. The frequency of these responses is shown
in Table 3.
(i) Confidence in doctor This was the strongest
theme emerging from patient’s responses, both
before and after receiving an explanation of the real
risks of stroke. Many felt that GPs held the expertise
and it was therefore pointless seeking advice and
not following it. Also, they felt that GPs would not
prescribe tablets unless they were of benefit.
Pt no: 34 ‘Yes I certainly would take them, because
I believe in the doctor and whatever the doctor tells
me I would do it.’
(ii) Control of blood pressure An awareness of the
importance of keeping blood pressure controlled
was another common opinion expressed by patients.
Following an explanation of the real risks of stroke,
fewer patients made reference to blood pressure
reduction, however, of those who did, the predominant feeling was that it was still necessary to take
anti-hypertensive tablets as prevention was far better than cure.
Pt. no: 4 ‘It’s a difficult one isn’t it? I think I still
would take them. You are on the safe side I think,
you’re doing something to try and stop it or keep it
level or whatever.’
(iii) Vague benefits Some patients referred to
vague benefits of taking tablets for blood pressure
reduction, demonstrating a belief that treatment
Hypertension in the elderly: attitudes of patients and GPs
M Cranney et al
541
Figure 1 Views of elderly patients and GPs: perceived risk of stroke with and without treatment for hypertension; compared with
actual results from the MRC trial.
1 = Perceived risk of stroke held by elderly patients, for untreated hypertensiion in their age group.
2 = Perceived risk of stroke held by GPs, for untreated elderly hypertensives.
3 = Actual risk of stroke in untreated elderly hypertensives found in MRC trial.
4 = Perceived risk of stroke held by elderly patients, for treated hypertensives in their age group.
5 = Perceived risk of stroke held by GPs, for treated elderly hypertensives.
6 = Actual risk of stroke in treated elderly hypertensives found in MRC trial.
Mean scores with 95% confidence intervals
95%
confidence
intervals
mean
1
47.87
37.67
2
12.65
9.21
3
4
23.23
16.77
5
5.93
4.35
6
42.77
10.93
5.4
20
5.14
3.65
Table 2 Willingness of elderly to accept drug treatment for hypertension
Yes
Decision to accept drug treatment for
72
hypertension, prior to seeing trial data. (96%)
Decision to accept drug treatment for
hypertension, after seeing trial data.
No
Don’t
know
Table 3 Reasons given by patients to explain their treatment
decisions (n = 75)
Reasons identified
2
1
(2.6%) (1.3%)
54
10
11
(72%) (13.3%) (14.6%)
must be helping them in some way; however, this
was very much related to patients’ trust in their GPs
advice. Following an explanation of the real risks of
stroke, perhaps paradoxically, more patients
expressed a belief in the vague benefits of treatment.
In addition to reasons already mentioned, some
patients now felt that, although the risks were less
than imagined, they would still rather not take the
chance that they could be one of the few people who
could suffer a stroke as a result of high blood pressure.
(iv) Prevention of stroke Some patients specifically stated that they would accept treatment, as it
was felt that taking tablets to reduce blood pressure,
although no guarantee, could give them some control and help protect against having a stroke.
Pt. No 8 ‘Yes I would. To keep you safe from having
a stroke of course.’
Number of patients giving a
particular reason (%)
Before seeing
trial data
After seeing
trial data
(i) Explanations given for accepting treatment
Confidence in doctor
38 (51%)
Control of blood pressure
15 (20%)
Vague benefits
13 (17%)
Prevention of stroke
8 (10%)
Side effects
3 (4%)
Any reduction worthwhile
0
Try and see
0
30
6
18
4
0
12
5
(ii) Explanations given for not accepting treatment
Side effects
2 (3%)
Benefits not as great as imagined
0
More information required
0
15 (20%)
6 (8%)
6 (8%)
Totals*
79
(40%)
(8%)
(24%)
(5%)
(16%)
(7%)
102
*Totals greater than sample size as some patients gave more than
one reason.
(v) Side effects Before we informed patients of the
real risks of stroke, five (7%) mentioned side effects,
and for two of the elderly, these were considered
sufficiently significant to dissuade them from
accepting therapy. However, after seeing the real
risks of stroke, 15 patients (20%) gave side effects
as the main reason why they would not accept treatment. This group felt that it was not worth enduring
Hypertension in the elderly: attitudes of patients and GPs
M Cranney et al
542
the unpleasant side effects of the tablets for the
apparently small reduction in the risk of stroke.
After the explanation of the real risks of stroke in
untreated and treated hypertension, confidence in
the doctor was still the most important theme
encouraging the elderly to accept treatment (see
Table 3). For those who would continue to accept
treatment, two new themes emerged: the first being
that any reduction in the risk of stroke, however limited, was useful; the second, was that treatment
would be cautiously taken, but reconsidered if any
adverse effects developed. For those patients who
changed their minds about accepting treatment, after
receiving the same information of the real risks of
stroke, two new themes of equal strength were identified from their responses. Some patients reported
that they would be unwilling to accept treatment
since the benefits were not as great as they had
imagined initially. Other patients stated that they
would consider accepting hypertensive treatment
only after receiving further information from their
doctor regarding such issues as immediate and long
term side effects of medication and other possible
restrictions that treatment might place upon their
lifestyle.
GP attitudes to treatment
In their management of the hypothetical patient (see
Appendix 1), only 51 (42%) of the GPs would have
treated the patient based on their pre-existing
knowledge. Fifty-three (44%) said they would not
treat the patient, with a further 17 (14%) uncertain.
There was no correlation between intention-to-treat
and perception of risk, nor between intention-totreat and perceived benefits of treatment. The
reasons given for treating or not treating initially are
shown in Table 4.
After seeing the actual risks and benefits reported
by the MRC trial,12 only 9% of the GPs changed their
minds. Six per cent more now opted not to treat,
citing lack of benefit as the reason. Three per cent
more opted to treat, citing the reduction of risk of
stroke as the reason.
Table 4 Explanations given by GPs for their initial treatment
decisions
Reasons identified
No. of
mentions*
(a) Would treat: n = 51 (42%)
(i) Reduced risk of stroke
(ii) Reduced myocardial infarction
(iii) Reduced morbidity or mortality
(b) Would not treat: n = 53 (44%)
(i) Treatment not worthwhile
(ii) Wish to consider other risk factors first
(iii) Wish to take more blood pressure
readings first
(iv) Fear of potential side effects
(c) No explanation offered: n = 17 (14%)
*Some respondents gave more than one explanation.
37
16
10
29
26
25
12
Discussion
The elderly greatly overestimated the risks of stroke
from hypertension and the benefits of treatment.
When shown the actual risks and benefits, a quarter
changed their minds and would consider not
accepting treatment. Active patient participation in
decision making improves control in conditions
such as hypertension.13 Furthermore, a recent
report14 has suggested that compliance by the elderly could be improved by carefully explaining to
them the need for medication and detailing possible
side effects. We wanted to know whether providing
such information, in a readily understandable way,
would affect the decision of the elderly to accept
treatment. We found that the visual aids used to convey the concept of risk greatly facilitated patient
understanding of this abstract concept. Surprisingly,
we found that despite knowing they had greatly
overestimated the benefits, the majority of older
people would still accept treatment. Most expressed
continuing confidence in the authority of the doctor
as the main reason for such concordance. GPs
should be aware of this deferential attitude, and
resist the temptation to practise ‘paternalistic’ medicine. Even those patients who have little desire to
be involved in the decision-making process, often
wish for further information on their condition.15
Although a wide variation occurred in the assessment by GPs of stroke risk in untreated and treated
hypertension (1–60% vs 0–30%), the mean scores
were reassuringly close to published assessments of
stroke risk in non-treatment and treatment groups.3
However, there was an interesting dichotomy of
treatment decisions amongst GPs. The scenario of an
individual patient was more likely to yield a positive ‘intention to treat’, than simply asking, ‘Do you
treat elderly hypertensives’.16 However, despite this
and the evident awareness of risks of untreated
hypertension and benefits of treatment, almost half
of the GPs stated they would not treat a 70-year-old
man with a blood pressure level that would certainly merit treatment according to all of the major
guidelines. Given their general awareness of the
absolute benefits, it is not surprising that very few
GPs (only 9%) changed their treatment decisions
after seeing the data from the MRC trial, and in no
consistent manner in contrast to the elderly.
Although more recent studies1–3 give slightly different stroke rates, we presented data from the MRC
trial because this was published in 1992 and was
more likely to be known by the participating GPs.
GPs have higher thresholds17 for defining and treating hypertension in the elderly than is recommended by various guidelines.4,18–21 Despite the
guidelines, GPs disagreed on whether the hypothetical patient should be treated, with almost half not
wishing to treat. This negative attitude of some GPs
towards treating the elderly hypertensive, previously noted also by others,22,23 is clearly not due
to ignorance of the true absolute benefits of treating
hypertension. The major reason, mentioned by over
half of the non-treating GPs, seems to have been that
they were not convinced that the benefits made
treatment worthwhile. The least common reason
Hypertension in the elderly: attitudes of patients and GPs
M Cranney et al
offered was concern about adverse effects of drugs
(in contrast to an earlier study where side effects
were the most common reason given for not
prescribing).24
Many of the GPs in our study wished to consider
other risk factors before initiating treatment.
Recently it has been suggested that GPs should make
a multi-factorial assessment of all risk factors before
commencing treatment,25 a view supported by the
New Zealand guidelines.19 However, in the elderly
the presence of a systolic pressure at or over 160
mm hg, or a diastolic pressure at or over 90 mm hg,
indicates a substantial and potentially reversible
risk of cardiovascular events, even in the absence of
other risk factors.5,26,27 Therefore, treating the elderly on the basis of hypertension alone, irrespective
of other risk factors, is still appropriate.28
Our sample of elderly patients was drawn from
a list known to one GP and only half accepted the
invitation to participate. This low response rate may
have produced a biased picture. Furthermore our
sample consisted entirely of healthy older patients
who have better relationships with their GP than ill
older patients, who are more critical of the care they
receive.29 This additional bias could have affected
the results and might explain the high level of confidence in the opinion of their GP. Our sample was
not representative of the whole population. However, it is recognised that qualitative data collection
is too time consuming and expensive to permit use
of a probability sample, as a result statistical representativeness is not normally sought in qualitative
research.11 The generalisability of qualitative
research is therefore accepted on a conceptual rather
than a numerical level.30,31 Furthermore, our sample
size of 75 was larger than most qualitative studies,
which usually do not interview more than 50 or 60
people.10 Indeed, it was decided that a second invitation need not be sent to the non-responders as a
sufficiently large enough sample had been obtained
for the purposes of qualitative assessment. We had
decided on a target population of 60–80 participants
partly for these considerations and partly because of
a limitation in human and financial resources. We
used independent interviewers, unknown by the
patients, to obtain more truthful opinions,32 and
hopefully obviated the bias of allegiance to their current GP when giving their responses.
Some GPs said they would not treat the hypothetical patient in the given scenario because they would
first like to collect more blood pressure readings.
Although this reflects a laudable adherence to guidelines, they had been informed when completing
their questionnaires that the figure of 170/94 mm Hg
was ‘sustained’, nevertheless these 25 GPs may have
misunderstood the scenario presented, and this was
a flaw in the questionnaire used.
In summary, our results demonstrate the deferential attitudes elderly patients hold towards their
GPs. We need to be aware of this and should endeavour to empower patients to contribute to decisions
about treatment, encouraging a ‘true partnership
between patient and prescriber’.9 It should also be
recognised that the elderly greatly overestimate the
benefits of treatment for hypertension. It appears
that a large percentage of GPs are unconvinced by
the published guidelines for this condition. Future
guideline development should therefore aim to be
simpler rather than more complex and should contain a summary of outcomes of treatment. This data
could be expressed in a readily accessible way,33
sensitive to the effects of different methods of data
presentation upon treatment decisions.34 Finally,
the use of visual aids can help patients co-operate
with their doctors in making decisions.
Acknowledgements
We would like to thank all of the patients and GPs
who co-operated in this study, two anonymous referees for their helpful comments and the North West
Regional Health Authority for funding this project.
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Appendix 1
Questionnaire administered to healthy elderly patients
You may know that high blood pressure can, in time, lead to a stroke. I am trying to find out how risky you think high
blood pressure is in relation to stroke.
Question 1) Here are 100 people aged over 65 years. with high blood pressure. How many of them do you think will
have a stroke in the next five years because of their high blood pressure? Visual aid 1: (This displays a representation
of 100 people, the respondent was asked to draw a line through the number they thought might have a stroke.)
Question 2) Here are another 100 people who also have high blood pressure. However they take tablets to control their
blood pressure. How many of them do you think will have a stroke in the next five years? (Visual aid 1: as above)
Question 3) If you (or someone you knew) were told by your doctor you had high blood pressure and were prescribed
tablets for it, would you take the tablets or encourage someone else to take them?
If yes, why?
If not, why not?
If unsure, what else would you want to know to make up your mind?
Question 4) (The correct values for questions 1 and 2 are now shown using visual aids 2 and 3) {ref MRC trial}12
Given what you now know about the risks of high blood pressure and the difference that treatment makes, would you
still take blood pressure tablets if your doctor prescribed them for you, and would you encourage someone else to
take them?
Visual Aid 2 Represents the risk of stroke in 100
untreated elderly hypertensives over five years. (5.26)
Visual Aid 3 Represents the risk of stroke in 100 treated
elderly hypertensives over five years. (3.57)
Hypertension in the elderly: attitudes of patients and GPs
M Cranney et al
GP Questionnaire
Question 1. Here are 100 people aged over 65 years with high blood pressure (⬎162/92). None of them take any tablets
for their blood pressure. Assuming none have any other risk factors, how many of them do you think will have a stroke
in the next five years? (Visual aid 1: as above.)
Question 2. Here are another 100 people aged over 65 years who also have high blood pressure (⬍162/92),
and no other risk factors, however they take tablets which effectively controls their blood pressure. How many of them
do you think will have a stroke in the next five years? (Visual aid 1: as above.)
Question 3. If you had a male patient aged 70 years with a BP 170/94 would you prescribe tablets for him to lower his BP?
(yes/no/don’t know) Please enter your reasons.
Question 4. (The correct values for questions 1 and 2 are now shown using visual aids 2 and 3: as above). Given what
you now know about the risks of high blood pressure and the difference that treatment makes, would your prescribing
habits remain the same as in question 3 or have you changed your viewpoint?
(i) remain the same:
(ii) change:
(please explain your decision)
545