we analyzed the sample of older adults ( 65 years of age or older , n = 3,810 ) participating in nhanes 19992004 , a continuing statistical survey of the noninstitutionalized civilian u.s .
all study participants have blood pressure measurements taken , whereas those in the nhanes morning subset ( n = 1,556 ) also have measurements taken of fasting plasma glucose and lipids . in accordance with american diabetes association criteria for epidemiological studies ( 20 ) ,
study participants were considered to have diabetes if they met one or more of the following conditions : their fasting plasma glucose level was 126 mg / dl , or they reported being told by a physician that they had diabetes , or they were taking glucose - lowering medications . a person was considered  aware 
if he / she responded positively to the question ,  have you ever been told by a doctor that you have diabetes or sugar diabetes ?  study participants who reported taking insulin or oral hypoglycemic agents were classified as  treated .
 a treated person was considered  controlled  if hba1c was less than 7% .
hypertension was defined in accordance with the seventh report of the joint national committee on prevention , detection , evaluation , and treatment of high blood pressure ( jnc 7 ) ( 7 ) .
a person was deemed to have hypertension if the nhanes examination indicated that , based on the average of three measurements , the systolic blood pressure ( sbp ) was 140 mm hg , or the diastolic blood pressure ( dbp ) was 90 mm hg , or if he / she reported current use of antihypertensive medication .
consequently , a person who may have been informed that he / she had hypertension , but who was not on medication and who tested normotensive on the day of the examination was not classified as a prevalent case of hypertension .
a person with hypertension according to the jnc 7 definition was considered  aware  if he / she gave a positive response to the question ,  have you ever been told by a doctor or other health professional that you had hypertension , also called high blood pressure ?  a person with hypertension was classified as  treated  if he / she reported taking antihypertensive medication at the time of the survey . a treated person was considered  controlled  if his / her average sbp was < 140 mm hg and average dbp was < 90 mm hg .
study participants were classified as having dyslipidemia if their low - density lipoprotein ( ldl ) cholesterol exceeded the appropriate risk - based threshold established by the national cholesterol education panel ( ncep ) adult treatment panel iii ( atp iii ) ( 4 ) or if they reported taking an antihyperlipidemic drug at the time of the examination .
similar to hypertension , this definition excludes persons who report having previously been told that they had high cholesterol but who test negative in nhanes and are not on medication
. a person with dyslipidemia according to the atp iii definition was considered  aware  if he / she gave a positive response to the question ,  have you ever been told by a doctor or other health professional that your blood cholesterol level was high ?  those who reported taking prescribed medicine to lower their blood cholesterol were considered  treated .
 controlled  if his / her ldl was lower than the appropriate ncep - atp iii goal .
we applied survey weights to the nhanes 19992004 data to derive population estimates of the prevalence of diabetes , hypertension , and dyslipidemia , as well as awareness , treatment , and control rates of these conditions among persons aged 65 or older .
calculations were performed using sas version 9.1 ( sas institute inc . , cary , nc , 2004 ) , and standard errors and p values computed using the procedure surveyfreq , which takes into account the effect on estimator variance attributable to the complex nhanes multistage stratified cluster sample design .
to determine independent risk factors , multivariate logistic regression models were estimated incorporating covariates for sex , age , usual place of care , doctor visits in past year , household income , living with spouse / partner , and education level .
we analyzed the sample of older adults ( 65 years of age or older , n = 3,810 ) participating in nhanes 19992004 , a continuing statistical survey of the noninstitutionalized civilian u.s .
all study participants have blood pressure measurements taken , whereas those in the nhanes morning subset ( n = 1,556 ) also have measurements taken of fasting plasma glucose and lipids .
in accordance with american diabetes association criteria for epidemiological studies ( 20 ) , study participants were considered to have diabetes if they met one or more of the following conditions : their fasting plasma glucose level was 126 mg / dl , or they reported being told by a physician that they had diabetes , or they were taking glucose - lowering medications . a person was considered 
if he / she responded positively to the question ,  have you ever been told by a doctor that you have diabetes or sugar diabetes ?  study participants who reported taking insulin or oral hypoglycemic agents were classified as  treated .
 a treated person was considered  controlled  if hba1c was less than 7% .
hypertension was defined in accordance with the seventh report of the joint national committee on prevention , detection , evaluation , and treatment of high blood pressure ( jnc 7 ) ( 7 ) .
a person was deemed to have hypertension if the nhanes examination indicated that , based on the average of three measurements , the systolic blood pressure ( sbp ) was 140 mm hg , or the diastolic blood pressure ( dbp ) was 90 mm hg , or if he / she reported current use of antihypertensive medication .
consequently , a person who may have been informed that he / she had hypertension , but who was not on medication and who tested normotensive on the day of the examination was not classified as a prevalent case of hypertension .
if he / she gave a positive response to the question ,  have you ever been told by a doctor or other health professional that you had hypertension , also called high blood pressure ?  a person with hypertension was classified as  treated  if he / she reported taking antihypertensive medication at the time of the survey .
a treated person was considered  controlled  if his / her average sbp was < 140 mm hg and average dbp was < 90 mm hg .
study participants were classified as having dyslipidemia if their low - density lipoprotein ( ldl ) cholesterol exceeded the appropriate risk - based threshold established by the national cholesterol education panel ( ncep ) adult treatment panel iii ( atp iii ) ( 4 ) or if they reported taking an antihyperlipidemic drug at the time of the examination .
similar to hypertension , this definition excludes persons who report having previously been told that they had high cholesterol but who test negative in nhanes and are not on medication
if he / she gave a positive response to the question ,  have you ever been told by a doctor or other health professional that your blood cholesterol level was high ? 
those who reported taking prescribed medicine to lower their blood cholesterol were considered  treated .
 controlled  if his / her ldl was lower than the appropriate ncep - atp iii goal .
we applied survey weights to the nhanes 19992004 data to derive population estimates of the prevalence of diabetes , hypertension , and dyslipidemia , as well as awareness , treatment , and control rates of these conditions among persons aged 65 or older .
calculations were performed using sas version 9.1 ( sas institute inc . , cary , nc , 2004 ) , and standard errors and p values computed using the procedure surveyfreq , which takes into account the effect on estimator variance attributable to the complex nhanes multistage stratified cluster sample design .
to determine independent risk factors , multivariate logistic regression models were estimated incorporating covariates for sex , age , usual place of care , doctor visits in past year , household income , living with spouse / partner , and education level .
table 1 shows the characteristics of adults aged 65 and older in the united states .
based on nhanes 19992004 , 55.2% are 6574 years old , more than half of all elders are married or living with a partner , and virtually all older adults are insured .
adults 65 years of age and older , national health and nutrition examination survey 19992004 the overall prevalence of hypertension ( table 2 ) among older adults is 70.8% , with prevalence increasing as age increases . women
have a significantly higher prevalence of hypertension than men ( 76.6% vs 63.0% ) and a significantly lower rate of control on treatment ( 42.9% vs 57.9% ) . at 54.0% , blood pressure control is higher among the youngest old ( age 6574 ) compared with 41.7% and 44.6% in the two older age groups ( ages 7584 , 85 ) , respectively .
overall , 42% of older adults have uncontrolled isolated systolic hypertension ( sbp 140 mm hg and dbp < 90 mm hg [ data not shown ] ) .
women have significantly higher levels than men of isolated sbp 140 mm hg and < 160 mm hg ( 28.6% vs 22.1% , p < .0002 ) and of isolated sbp of 160 mm hg or greater ( 21.0% vs 10.1% , p < .0001 ) . isolated systolic hypertension accounts for 88.4% of undiagnosed hypertension among older adults .
hypertension , dyslipidemia , and diabetes prevalence , awareness , treatment , and control among u.s .
adults 65 years of age and older , national health and nutrition examination survey 19992004 notes : p  .05 difference between male and female , or between the age group and age 6574 .
p  .01 difference between male and female , or between the age group and age 6574 .
p  .001 difference between male and female , or between the age group and age 6574 .
men are significantly less likely to be aware of their condition than women ( 59.1% vs 71.1% ) , although both genders are equally likely to be treated ( 40.9% vs 45.1% ) .
the oldest old have a significantly lower prevalence , are less aware , and have a lower treatment rate for dyslipidemia than the youngest old .
two thirds of all older adults medically treated for dyslipidemia reach their ldl cholesterol goal .
diabetes ( table 2 ) affects 21.2% of adults 65 years of age and older .
the awareness rate for diabetes ( 71.4% ) is driven by a significantly higher awareness among women than among men ( 78.5% vs 63.6% ) .
half of all prevalent diabetes cases are treated pharmacologically , and only half of all treated cases reach hba1c goal attainment of < 7% .
tables 3 , 4 , and 5 present the results of estimating separate logistic regression models for the rates of awareness , pharmacologic treatment , and control of the three conditions , adjusting for the effects of age , sex , education , number of doctor visits , living arrangement , having a usual health care provider and annual household income .
logistic regression models of predictors of awareness , treatment , and control of hypertension among u.s .
adults 65 years of age and older , national health and nutrition examination survey 19992004 notes : or = odds ratio ; ci = confidence interval .
logistic regression models of predictors of awareness , treatment , and control of dyslipidemia among u.s .
adults aged 65 and older , national health and nutrition examination survey 19992004 notes : or = odds ratio ; ci = confidence interval .
logistic regression models of predictors of awareness , treatment , and control of diabetes among u.s .
adults aged 65 and older , national health and nutrition examination survey 19992004 notes : or = odds ratio ; ci = confidence interval . for elders with hypertension , higher age
is associated with lower rates of awareness ( odds ratio [ or ] = 0.71 [ age 7584 ] and 0.54 [ age 85 ] vs age 6574 ) , treatment ( or = 0.70 [ age 7584 ] and 0.60 [ age 85 ] vs age 6574 ) , and control ( or = 0.59 [ age 7584 ] vs age 6574 ) . among those with dyslipidemia ,
the oldest ( age 85 ) have significantly lower rates of awareness and treatment ( or = 0.29 and 0.38 vs age 6574 , respectively ) . although there are no significant differences between the sexes in awareness or treatment for hypertension , women on treatment are only half as likely as men to have their blood pressure controlled ( or = 0.51 ) .
women are more likely than men to be aware and treated for dyslipidemia ( or = 2.60 and 1.56 , respectively ) and more likely to be aware of their diabetes ( or = 3.14 ) .
there are no significant associations between education ( high school or more ) and awareness , treatment , or control of hypertension and diabetes , however , education is positively associated with awareness ( or = 1.39 ) and treatment ( or = 1.62 ) of dyslipidemia .
the number of doctor visits in the past year is positively and strongly associated with awareness and treatment of all three conditions .
living arrangement ( married / living with partner ) is not associated with awareness , treatment , or control of any of the conditions .
elders who have a usual health care provider are far more likely than those who do not have a usual provider to be aware ( or = 2.87 ) and treated ( or = 5.10 ) for their hypertension .
elders with low annual household income ( less than $ 15,000 in 2002 dollars ) are much less likely than those with income more than $ 45,000 to be aware or controlled on treatment for their dyslipidemia ( or = 0.36 and 0.39 , respectively ) .
those in the middle - income range of $ 15,000$45,000 are less likely than persons with household income more than $ 45,000 to be aware of their diabetes ( or = 0.36 ) .
tables 3 , 4 , and 5 present the results of estimating separate logistic regression models for the rates of awareness , pharmacologic treatment , and control of the three conditions , adjusting for the effects of age , sex , education , number of doctor visits , living arrangement , having a usual health care provider and annual household income . logistic regression models of predictors of awareness , treatment , and control of hypertension among u.s . adults 65 years of age and older , national health and nutrition examination survey 19992004 notes : or = odds ratio ; ci = confidence interval . logistic regression models of predictors of awareness , treatment , and control of dyslipidemia among u.s . adults aged 65 and older , national health and nutrition examination survey 19992004 notes : or = odds ratio ; ci = confidence interval .
logistic regression models of predictors of awareness , treatment , and control of diabetes among u.s .
adults aged 65 and older , national health and nutrition examination survey 19992004 notes : or = odds ratio ; ci = confidence interval . for elders with hypertension , higher age
is associated with lower rates of awareness ( odds ratio [ or ] = 0.71 [ age 7584 ] and 0.54 [ age 85 ] vs age 6574 ) , treatment ( or = 0.70 [ age 7584 ] and 0.60 [ age 85 ] vs age 6574 ) , and control ( or = 0.59 [ age 7584 ] vs age 6574 ) . among those with dyslipidemia ,
the oldest ( age 85 ) have significantly lower rates of awareness and treatment ( or = 0.29 and 0.38 vs age 6574 , respectively ) . although there are no significant differences between the sexes in awareness or treatment for hypertension , women on treatment are only half as likely as men to have their blood pressure controlled ( or = 0.51 ) .
women are more likely than men to be aware and treated for dyslipidemia ( or = 2.60 and 1.56 , respectively ) and more likely to be aware of their diabetes ( or = 3.14 ) .
there are no significant associations between education ( high school or more ) and awareness , treatment , or control of hypertension and diabetes , however , education is positively associated with awareness ( or = 1.39 ) and treatment ( or = 1.62 ) of dyslipidemia .
the number of doctor visits in the past year is positively and strongly associated with awareness and treatment of all three conditions .
living arrangement ( married / living with partner ) is not associated with awareness , treatment , or control of any of the conditions .
elders who have a usual health care provider are far more likely than those who do not have a usual provider to be aware ( or = 2.87 ) and treated ( or = 5.10 ) for their hypertension .
elders with low annual household income ( less than $ 15,000 in 2002 dollars ) are much less likely than those with income more than $ 45,000 to be aware or controlled on treatment for their dyslipidemia ( or = 0.36 and 0.39 , respectively ) .
those in the middle - income range of $ 15,000$45,000 are less likely than persons with household income more than $ 45,000 to be aware of their diabetes ( or = 0.36 ) .
using the combined nhanes 19992004 data , these analyses provide up - to - date estimates of prevalence , awareness , treatment , and control of hypertension , dyslipidemia , and diabetes among adults aged 65 and older in the united states .
our results are consistent with previous studies of prevalence of these three cardiovascular risk factors in older adults ( 810,16,17 ) ; expand the body of knowledge regarding awareness , treatment , and control rates ; and identify gender disparities among the rates .
we found that older women are more likely than older men to have hypertension , equally likely to be aware and treated , but less likely to have their blood pressure controlled on pharmacotherapy .
this finding is consistent with recent studies showing a positive trend of increasing blood pressure control among older adults ( age 60 ) in the nhanes study population ( 18,21 ) .
the improvement in control may be due , in part , to physician education and changing practice patterns based on the jnc 7 guidelines ( 7 ) .
notwithstanding this success , in the present study , women are only half as likely as men ( after adjusting for covariates ) to attain blood pressure goal . a similar finding for women ( age 20 )
was reported in a previous nhanes 19992002 study of racial disparities in hypertension , after adjusting for race ( 22 ) , suggesting that additional blood pressure control programs specifically targeted toward women are warranted . the paradigm shift of the jnc emphasizing the importance of diagnosing and treating systolic hypertension among older adults ( 23,24 ) further merits the need for such gender - specific programs .
we found the prevalence of dyslipidemia to be similar by gender , with women more likely to be aware and treated .
although overall treatment is only 43% , there has been a suggestive upward trend of pharmacological treatment for dyslipidemia among older adults ( age 60 ) , based on estimates from the nhanes data ( 16 ) .
this trend may be attributed to some degree , to increasing adoption of the ncep guidelines ( 4 ) .
control rates for dyslipidemia in this study are similar by gender and by age groups .
our study found that women with diabetes are more likely than men to be aware of their condition and that only 50% of patients on pharmacotherapy are controlled ( hba1c < 7% ) .
other studies in various clinical settings have documented poor diabetes control among the elderly adults ( 25,26 ) .
this study provides newer evidence that confirms the need for improved quality of care . in our study ,
continued physician efforts to improve treatment rates and successfully treat patients to goal are needed .
although our study shows that increasing numbers of doctor visits are associated with awareness and treatment for all three conditions , and with goal attainment for dyslipidemia , the interpretation of this finding is ambiguous . it may be that more frequent visits provide added opportunity for physicians to detect and treat undiagnosed disease , or the causality may be reversed , and those who already are aware and/or treated make more visits for the purpose of refilling prescriptions or monitoring treatment effectiveness .
an important national public health effort to reduce cvd risk factor burden through the healthy people 2010 has had ongoing successes ( 16,27 ) , and knowledge of our study 's findings on gender differences in awareness and control may be useful to clinicians in the effort to improve outcomes . the strengths of this study include its population - based sampling frame and the availability of clinical measurements to determine undiagnosed and diagnosed disease prevalence and to determine goal attainment . additionally , using 6 years of nhanes data
provides a large sample and precise estimates of conditions affecting older adults . to our knowledge
, this is the first study to use nhanes 19992004 to report on the prevalence and management of cvd risk factors among adults 65 years and older
a limitation in our study is that physician - specific variables , such as practitioner age , group practice size and setting ( eg , university medical center ) , and practice patterns are not available in nhanes .
we used a blood pressure goal of < 140/90 mm hg for adults with hypertension with and without diabetes , a method that has been applied in other studies ( 8,9 ) .
the current blood pressure goal for adults with hypertension and with diabetes is < 130/80 mm hg ( 7 ) .
applying this threshold to adults with hypertension and with diabetes would result in a lower estimate of blood pressure control ( 7,9 ) .
women with hypertension are disproportionately affected by higher prevalence and lower control rates than men .
women with dyslipidemia or diabetes are more likely than men to be aware of their condition .
for all three conditions , improvements in treatment and control rates are needed . in light of the expected growth in this population ,
 backgroundadults aged 65 and older are disproportionately affected by hypertension , dyslipidemia , and diabetes , which are established risk factors for cardiovascular disease ( cvd ) . 
 although risk reduction strategies among older adults , including control of cvd risk factors , can lead to a decline in premature cvd morbidity and mortality , the prevalence of these risk factors has generally increased in the past decade among elders and risk factor control rates have been suboptimal . 
 we assess prevalence , awareness , treatment , and control rates among u.s . 
 adults aged 65 and older with respect to hypertension , dyslipidemia , and diabetes and describe predictors associated with awareness and management of these factors.methodsanalysis of nationally representative data collected from adults aged 65 and older ( n = 3,810 ) participating in the national health and nutrition examination survey 19992004.resultswomen have a significantly higher prevalence of hypertension than men ( 76.6% vs 63.0% ) and a significantly lower rate of control when treated pharmacologically ( 42.9% vs 57.9% ) . 
 dyslipidemia prevalence is 60.3% overall , and women are significantly more likely to be aware of their condition than men ( 71.1% vs 59.1% ) . 
 diabetes affects 21.2% of older adults , and 50.9% of prevalent cases are treated pharmacologically . 
 goal attainment among those treated is problematic for all three conditions  hypertension ( 48.8% ) , dyslipidemia ( 64.9% ) , and diabetes ( 50.4% ) . having two or more doctor visits annually 
 is associated with goal attainment for dyslipidemia.conclusionsknowledge of cardiovascular health in older adults and understanding gender gaps in awareness can help physicians and policymakers improve disease management and patient education programs . 
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Predictors of Awareness, Treatment, and Control
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