Abstract
Objective:
This study aimed to identify the factors influencing home blood pressure measurement (HBPM) continuation in community-dwelling older adults.
Methods:
A longitudinal analysis used the NOSE study intervention group datasets. The participants were encouraged HBPM with self-monitoring devices provided to them twice in the morning and twice in the evening. Every 7-day interval from the HBPM start date was defined as 1 week, and the number of HBPMs per week was counted. The first week in which the number of HBPMs was zero was defined as the week in which HBPM was discontinued. Participants who did not experienced discontinuation until the end of the observation period were considered complete survivors in the survival time analysis.
Results:
Data from 437 participants were included in the analysis. Of these, 120 (27.5%) discontinued HBPM. In univariate analysis, factors significantly associated with HBPM discontinuation included exercise habits [hazard ratio per one unit 0.47; 95% confidence interval (CI) 0.31-0.69], social participation (hazard ratio 0.65; 95% CI 0.42–0.99), MoCA-J score (hazard ratio 0.94; 95% CI 0.90–0.98), and frailty (hazard ratio 5.20; 95% CI 2.87–9.43). In multivariate analysis, factors significantly associated with HBPM discontinuation included sex (hazard ratio 0.55; 95% CI 0.32–0.95; ref. = female individuals), smoking history (hazard ratio 1.69; 95% CI 1.02–2.80), exercise habits (hazard ratio 0.51; 95% CI 0.30–0.85), MoCA-J score (hazard ratio 0.93; 95% CI 0.88–0.98), and frailty (hazard ratio 3.31; 95% CI 1.50–7.29).
Conclusion:
Among community-dwelling older adults, female sex, smoking history, lack of exercise, cognitive decline, and frailty were identified as factors influencing HBPM discontinuation.
Keywords: aged, community-dwelling older adults, continuation, hypertension, public health, self-blood pressure monitoring, self-care
INTRODUCTION
Hypertension is the most significant risk factor for mortality caused by cerebrovascular and cardiovascular diseases (CVD) [1], and appropriate blood pressure (BP) control is critical for the prevention of CVD. However, only approximately 30% of the patients with hypertension are treated and adequately controlled [2,3].
Continuous daily home blood pressure measurements (HBPMs) have been reported to contribute to better BP control. HBP is more reliable and reproducible than office BP and is a better predictor of CVD [4]. For treated individuals, treatment based on continuous HBPMs improved BP after 1 year, compared with treatment based on office BP measurement [5]. Godwin et al.[6] reported that HBPMs at least once per week resulted in a decrease in DBP in men. Continuous HBPMs has been suggested to improve medication adherence [7,8] and to cause beneficial changes in other lifestyle factors related to hypertension management [9]. For untreated individuals, HBPM is effective in detecting masked or morning hypertension [7,10], and studies have shown that those who measure HBP are more likely to proceed with treatment than those who do not [11].
Despite the usefulness of HBPM, the number of individuals who actively measure their HBPs remains limited. Only approximately 50–60% of those taking antihypertensive medications measure their HBPs weekly or more frequently [12,13]. Among those not taking antihypertensive medications, approximately 10% measured their HBPs at least twice per month [12].
Previous studies have examined the factors that influence HBPM in hypertensive population [14] and in middle-aged population without antihypertensive medication [12]. However, the previous study, which involved patients not taking antihypertensive medications, was a cross-sectional study based on questionnaires, and thus, it could not provide findings on the continuation of HBPM using objective data. Regardless of these previous studies, factors influencing the continuation of HBPM in community-dwelling older adults, including those not taking antihypertensive medications, remain unclear.
Therefore, this study aimed to identify factors that may influence the continuation of HBPM in community-dwelling older adults with or without antihypertensive medication through long-term observation based on objective data. As this group is expected to include prehypertensive or untreated individuals, continuous HBPMs and clarifying its associated factors may be beneficial in the management of hypertension.
METHODS
Study participants
The study participants were selected from a dataset contained in the NOSE study, a prospective cohort study conducted continuously since 2020. The purpose of the NOSE study is to determine the effect of HBPM and recording on preventing the development of CVD, frailty, and cognitive decline. Participants in the NOSE study were recruited between August 2020 and August 2021 from community-dwelling adults aged at least 40 years in Nose Town, a regional town with approximately 10 000 inhabitants located in Osaka Prefecture, Japan. The participants were divided into intervention and nonintervention groups based on their residence in 44 districts. Each district was allocated to either the intervention or nonintervention group to ensure that sex distribution, aging rates, health check participation rates, and turnout was nearly equal between both groups. The NOSE study was registered in the UMIN-clinical trial Registry (No. UMIN000039349). Participants were recruited through the town's newsletter, health checkup sites, community activity sites, and mass COVID-19 vaccination sites. Baseline enrollment was 1153 participants, representing 15.9% of the Nose Town residents aged at least 40 years. At baseline, each participant attended 1 of 79 venue surveys conducted during the recruitment period. Venue surveys were conducted at the Health and Welfare Center and community centers located in 38 of the 44 districts in Nose Town. Some community centers were excluded because of limited space. Participants in the intervention group were provided a self-monitoring HBPM device (HEM-7281T, OMRON HEALTHCARE Co. Ltd., Kyoto, Japan) and a BP-recording notebook at the baseline survey. They were encouraged to measure their HBPs twice in the morning and twice in the evening from the day of the baseline survey, according to the HBPM instructions in the guidelines of the Japanese Society of Hypertension [3], and to record their HBPs in a notebook. BP notebooks were collected approximately every 6 months after each participant's baseline survey. On the basis of these records, the hypertension specialist on the study team provided feedback to the participants.
Participants in this study were from the intervention group of the NOSE study. Of the 677 participants enrolled in the intervention group, 216 had end-of-year ages less than 64 years, 6 had missing entries in key items of the questionnaire, and 18 for whom BP data could never be collected and HBPM continuity could not be defined; therefore, these participants were excluded. The remaining 437 participants were included in this study. The BP data collected between February 2020 and December 2022 was analyzed. This study was conducted in accordance with the principles of the Declaration of Helsinki. All study procedures were approved by the Ethics Committee of Osaka University Hospital (19433-4). Written informed consent was obtained from all the participants.
Definition of home blood pressure measurement continuation
To analyze the factors that contribute to the continuation of HBPM using survival time analysis, discontinuation of HBPM was defined. The interval of every 7 days from the start date of each participant's HBPM was defined as 1 week. The number of HBPMs per week was counted from the BP records, and the first week in which the number of HBPMs per week was zero, regardless of the reason, was defined as the week in which HBPM was discontinued. The number of weeks for which HBPM was continued for each participant was counted. Participants who did not experience discontinuation until the end of the observation period were treated as complete survivors in the survival time analysis.
Criteria of blood pressure
Home morning BP was determined using the average of the first and second HBPs in the mornings during the observation period. Morning BP was measured by the participants themselves in a sitting position, within 1 h waking up, before taking antihypertensive medication, before breakfast, and after urination. According to the guidelines of the Japanese Society of Hypertension [3], individuals with SBPs of at least 135 mmHg and/or DBPs of at least 85 mmHg were classified as having hypertension at home. Office hypertension was determined by calculating the average of the first and second BPs taken at the survey site, with a SBP of at least 140 mmHg and/or a DBP of at least 90 mmHg used as the criteria.
Independent variable
Participants were interviewed and physically assessed by a physician or nurse. Questionnaires were administered for the following items: living status, self-reported economic status, educational attainment, medical history, antihypertensive medications, smoking history, drinking habits, exercise habits, employment status, and social participation. The self-reported economic status was determined based on five response options: ‘very comfortable’, ‘comfortable’, ‘normal’, ‘not comfortable’, and ‘very uncomfortable’. Of these, ‘very comfortable’ and ‘comfortable’ were categorized as ‘high,’ while ‘uncomfortable’ and ‘very uncomfortable’ were categorized as ‘low’. Educational attainment was categorized as less than 9, 10–12, or 13 or more based on the Japanese education system. Those who drank alcohol at least once per week were classified as having a drinking habit. Those who answered ‘no’ to both questions, ‘Do you engage in light exercise for 30 min or more per one time?’ and ‘Do you walk for at least 1 h per day or do the equivalent?’ were classified as not exercising. Social participation was defined as attending a community activity place, participating in hobbies or recreational circles, joining a voluntary group, belonging to a neighborhood association or community organization, joining a senior citizen club, participating in religious events, learning activities, or any other form of social activity at least once per month. Cognitive function was assessed using the Japanese version of the Montreal Cognitive Assessment (MoCA-J) [15], with total scores ranging from 0 to 30. Higher scores indicated better cognitive function. Frailty was determined using the revised Japanese version of the Cardiovascular Health Study (J-CHS) criteria [16]. Frailty was defined as having three or more of the following five criteria: weight loss, low grip strength, fatigue, slow walking speed, and low physical activity. Prefrailty was defined as meeting one or two of these criteria, whereas individuals meeting none of these criteria were classified as robust.
Statistical analysis
The participants were divided into Continued and Discontinued HBPM groups according to the definition of HBPM continuation. We conducted a descriptive analysis of the participants, Pearson's chi-square test for categorical variables, and the Mann–Whitney U test for continuous variables to compare the characteristics between the two groups. Cox proportional hazards regression analysis was performed to estimate the hazard ratios per one unit (hazard ratios) and 95% confidence intervals (CIs), with age, sex, BMI, office SBP, antihypertensive medication use, smoking history drinking habits, exercise habits, history of CVD, diabetes, dyslipidemia, living alone, educational attainment, self-reported economic status, employment, social participation, MoCA-J score, and frailty as covariates. Statistical significance was set at P less than 0.05. Statistical analyses were performed using SPSS Statistics 28.0 (IBM Japan, Tokyo, Japan).
RESULTS
Clinical characteristics of study participants are summarized in Table 1. The proportion of participants taking antihypertensive medication was 40%, and the prevalence rates of office and home hypertension were 51 and 43%, respectively. Trends in HBPM continuation rates during the follow-up period are shown in Fig. 1. During the follow-up period (median follow-up, 1.9 years), 120 participants (27.5%) discontinued HBPM.
TABLE 1.
Clinical characteristics of the study participants
| n = 437 | |
| Follow-up period (years) | 1.9 [1.2, 1.9] |
| Age (years) | 72 (69, 77] |
| Sex, male (%) | 171 (39.1) |
| BMI (kg/m2) | 23.2 [21.2, 25.3] |
| Blood pressure | |
| Office systolic (mmHg) | 138.0 [126.5, 151.0] |
| Office diastolic (mmHg) | 81.5 [74.0, 89.0] |
| Home morning systolic (mmHg) | 130.9 [123.0, 138.8] |
| Home morning diastolic (mmHg) | 79.1 [73.4, 83.7] |
| Antihypertensive medication use (%) | 175 (40.0) |
| Office hypertension a (%) | 223 (51.0) |
| Home hypertension b (%) | 188 (43.0) |
| Antihypertensive medication use (%) | 99 (52.7) |
| Antihypertensive medication nonuse (%) | 89 (47.3) |
| Undiagnosed hypertension c (%) | 78 (87.6) |
| Lifestyle habits | |
| Smoking history (%) | 157 (35.9) |
| Drinking habits (%) | 147 (33.6) |
| Exercise habits (%) | 359 (82.2) |
| Medical history | |
| History of CVD (%) | 113 (25.9) |
| Diabetes (%) | 58 (13.3) |
| Dyslipidemia (%) | 173 (39.6) |
| Socioeconomic status | |
| Living alone (%) | 68 (15.6) |
| Educational attainment (≤9/10–12/≥13, years, %) | 50 (11.4)/250(57.2)/137 (31.4) |
| Self-reported economic status (low/normal/high, %) | 94(21.5)/187(42.8)/156(35.7) |
| Employment (%) | 161 (36.8) |
| Social participation (%) | 358 (81.9) |
| MoCA-J score, points | 25 [22, 27] |
| Frailty (robust/prefrail/frail, %) | 210(48.1)/208(47.6)/19 (4.3) |
Values are presented as frequencies or medians [interquartile range]. CVD, cardiovascular disease; MoCA-J, Japanese version of the Montreal Cognitive Assessment.
Office hypertension was defined as a BP of 140/90 mmHg or higher at the survey site.
Home hypertension was defined as a mean home morning BP of 135/85 mmHg or higher during the observation period.
Undiagnosed hypertension was defined as those who answered that they had never been diagnosed with hypertension during a medical history interview conducted by a physician or nurse.
FIGURE 1.
Trends in home blood pressure measurement continuation rates during the observation period.
Table 2 compares the characteristics of the Continued and Discontinued HBPM groups. The Discontinued HBPM group had a significantly lower percentage of participants with regular exercise habits than the Continued HBPM group (P < 0.001). In addition, the MoCA-J scores were significantly lower (P = 0.043), and the proportion of frail individuals was significantly higher (P < 0.001) in the Discontinued HBPM group.
TABLE 2.
Comparison of characteristics between the continued and discontinued home blood pressure measurement groups
| Continued HBPM (n = 317; 72.5%) | Discontinued HBPM (n = 120; 27.5%) | P value | |
| Follow-up period (year) | 1.9 [1.5, 1.9] | 0.7 [0.4, 1.1] | <0.001 |
| Sex (male) | 125 (39.6) | 46 (38.3) | 0.913 |
| Age (years) | 72 [69, 77] | 73 [69, 78] | 0.141 |
| BMI (kg/m2) | 23.2 [21.3, 25.3] | 23.2 [21.1, 25.7] | 0.755 |
| Office SBP (mmHg) | 136.5 [125.5, 150.8] | 141.0 [130.1, 151.0] | 0.146 |
| Office DBP (mmHg) | 81.5 [73.8, 89.5] | 81.3 [74.5, 87.4] | 0.743 |
| Home morning SBP (mmHg) | 130.9 [122.6, 137.8] | 131.8 [123.8, 142.1] | 0.076 |
| Home morning DBP (mmHg) | 78.8 [73.1, 83.7] | 79.3 [74.0, 83.7] | 0.454 |
| Antihypertensive medication use (yes) | 128 (40.4) | 47 (39.2) | 0.828 |
| Smoking history (yes) | 109 (34.4) | 48 (40.0) | 0.315 |
| Drinking habits (yes) | 105 (33.1) | 42 (35.0) | 0.734 |
| Exercise habits (yes) | 273 (86.1) | 86 (71.7) | <0.001 |
| History of CVD (yes) | 84 (26.5) | 29 (24.2) | 0.714 |
| Diabetes (yes) | 41 (12.9) | 17 (14.2) | 0.753 |
| Dyslipidemia (yes) | 121 (38.2) | 52 (43.3) | 0.327 |
| Living alone (yes) | 47 (14.8) | 21 (17.5) | 0.554 |
| Educational attainment | |||
| ≤9 years | 33 (10.4) | 17 (14.2) | 0.234 |
| 10–12 years | 178 (56.2) | 72 (60.0) | |
| ≥13 years | 106 (33.4) | 31 (25.8) | |
| Self-reported economic status | |||
| Low | 62 (19.6) | 32 (26.7) | 0.093 |
| Normal | 133 (42.0) | 54 (45.0) | |
| High | 122 (38.5) | 34 (28.3) | |
| Employment, yes | 113 (35.6) | 48 (40.0) | 0.437 |
| Social participation (yes) | 266 (83.9) | 92 (76.7) | 0.094 |
| MoCA-J score (points) | 25.0 [22.0, 27.0] | 24.5 [21.0, 27.0] | 0.043 |
| Frailty | |||
| Robust | 159 (50.2) | 51 (42.5) | <0.001 |
| Prefrail | 153 (48.3) | 55 (45.8) | |
| Frail | 5 (1.6) | 14 (11.7) |
Values are presented as frequencies or medians [interquartile ranges]. The chi-square test was used for categorical variables and the Mann–Whitney U test was used for continuous variables. CVD, cardiovascular disease; MoCA-J, Japanese version of the Montreal Cognitive Assessment.
The results of the Cox proportional hazards regression analysis are presented in Table 3. In univariate analysis, factors significantly associated with discontinuation of HBPM included exercise habits (hazard ratio 0.47; 95% CI 0.31–0.69), social participation (hazard ratio 0.65; 95% CI 0.42–0.99), MoCA-J scores (hazard ratio 0.94; 95% CI 0.90–0.98), and frailty (hazard ratio 5.20; 95% CI 2.87–9.43). In multivariate analysis, factors significantly associated with discontinuation of HBPM included sex (hazard ratio 0.55; 95% CI 0.32–0.95, ref. = female), smoking history (hazard ratio 1.69; 95% CI 1.02–2.80), exercise habits (hazard ratio 0.51; 95% CI 0.30–0.85), MoCA-J scores (hazard ratio 0.93; 95% CI 0.88–0.98), and frailty (hazard ratio 3.31; 95% CI 1.50–7.29). In addition, sub-analyses were performed to identify mediating variables for sex and smoking history, which were not significantly associated in the univariate analysis (Supplemental Tables 1 and 2).
TABLE 3.
Cox proportional hazards regression analysis of discontinued home blood pressure measurement
| Univariate analysis | Multivariate analysis | |||
| HR [95% CI] | P value | HR [95% CI] | P value | |
| Age (year) | 1.03 [1.00–1.06] | 0.084 | 1.01 [0.97–1.05] | 0.708 |
| Sex (ref. = female) | 0.97 [0.67–1.40] | 0.862 | 0.55 [0.32–0.95] | 0.033 |
| BMI | 1.02 [0.96–1.08] | 0.489 | 1.02 [0.96–1.08] | 0.593 |
| Office SBP (mmHg) | 1.01 [1.00–1.01] | 0.259 | 1.01 [1.00–1.02] | 0.314 |
| Antihypertensive medication use | 0.94 [0.65–1.36] | 0.757 | 0.74 [0.49–1.12] | 0.156 |
| Smoking history | 1.25 [0.87–1.80] | 0.230 | 1.69 [1.02–2.80] | 0.041 |
| Drinking habits | 1.09 [0.75–1.59] | 0.644 | 1.23 [0.79–1.91] | 0.351 |
| Exercise habits | 0.47 [0.31–0.69] | <0.001 | 0.51 [0.30–0.85] | 0.010 |
| History of CVD | 0.90 [0.59–1.37] | 0.625 | 0.92 [0.59–1.43] | 0.710 |
| Diabetes | 1.14 [0.68–1.91] | 0.609 | 0.98 [0.57–1.70] | 0.952 |
| Dyslipidemia | 1.17 [0.81–1.68] | 0.399 | 1.40 [0.95–2.06] | 0.092 |
| Living alone | 1.24 [0.78–1.99] | 0.368 | 1.30 [0.78–2.17] | 0.305 |
| Educational attainment (ref. = ≥13 years) | ||||
| ≤9 years | 1.61 [0.89–2.91] | 0.114 | 1.04 [0.53–2.03] | 0.910 |
| 10–12 years | 1.32 [0.87–2.01] | 0.195 | 1.18 [0.75–1.86] | 0.462 |
| Self-reported economic status (ref. = high) | ||||
| Low | 1.62 [1.00–2.62] | 0.051 | 1.25 [0.74–2.10] | 0.406 |
| Normal | 1.35 [0.88–2.07] | 0.172 | 1.36 [0.87–2.12] | 0.181 |
| Employment | 1.22 [0.84–1.75] | 0.296 | 1.33 [0.89–1.99] | 0.170 |
| Social participation | 0.65 [0.42–0.99] | 0.044 | 0.64 [0.40–1.01] | 0.055 |
| MoCA-J score, point | 0.94 [0.90–0.98] | 0.004 | 0.93 [0.88–0.98] | 0.003 |
| Frailty (ref. = robust) | ||||
| Prefrail | 1.13 [0.77–1.65] | 0.534 | 0.87 [0.55–1.37] | 0.539 |
| Frail | 5.20 [2.87–9.43] | <0.001 | 3.31 [1.50–7.29] | 0.003 |
CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio; MoCA-J, Japanese version of the Montreal Cognitive Assessment.
DISCUSSION
Factors associated with HBPM discontinuation included female sex, smoking history, lack of exercise habits, cognitive decline, and frailty. This is the first study to show the factors influencing the continuation of HBPM in community-dwelling older adults in the long-term observation (median follow-up, 1.9 years). These results are consistent with previous studies that may or may not have used objective data.
Vickneson et al.[14] found that older age and a family history of hypertension were positively correlated with the continuation of HBPM in patients taking antihypertensive medications, whereas smoking, high BMI, and higher baseline BP were negatively correlated. Tatsumi et al.[12] conducted a questionnaire survey of a worksite population aged from 40 to 65 years and reported that older age, high BP levels (≥140/90 mmHg), and healthy lifestyles were factors for HBPM among those without antihypertensive medications. Regarding smoking history and exercise habits, these results are consistent with those of previous studies.
Female sex was associated with discontinuation of HBPM. Univariate analysis showed no association, possibly because of the higher proportion of male individuals with smoking history and lower MoCA-J scores. According to the Survey on Time Use and Leisure Activities, older adult men reported spending 42 min per week on household chores, while older adult women reported spending 182 min per week on household chores [17]. As the present study requests participants HBPM twice in the morning and twice in the evening, and we speculate that older women may find it more difficult to record HBPM during those hours than men, which may have resulted in the significant difference.
Smoking history was associated with discontinuation of HBPM. Univariate analysis showed no association, possibly because of a lower proportion of male individuals with no smoking history. Although previous studies have reported results limited to patients with hypertension [14], the present study revealed a similar trend in community-dwelling older adults with or without antihypertensive medication. These results are consistent with previous findings that smoking is negatively correlated with various health habits [18]. Previous studies have also reported a negative correlation between smoking history and ownership of HBPM devices [19]. These results suggest the need for measurement support for smokers when designing and promoting BP control programs.
Lack of exercise habits was also associated with discontinuation of HBPM [12]. Although previous studies have reported a correlation between exercise habits and continued HBPM among women in the working population [12], the present study found similar results among community-dwelling older adults. Research suggests that individuals who engage in regular exercise are more likely to adopt healthy habits [20]. Therefore, those who exercise regularly may more readily adopt health-monitoring behaviors, such as self-measuring their BP regularly.
Cognitive decline and frailty were associated with HBPM discontinuation. This novel perspective highlights an important issue in the management of BP in older adults. Cognitive decline can lead to a decreased ability to manage one's own health and reduce competence in daily living [21,22]. Furthermore, a strong correlation between frailty and loss of interest has been demonstrated in community-dwelling older adults [23], which can complicate HBPM. However, HBPM is important in patients with both hypertension and frailty because masked hypertension is frequently reported [24]. Therefore, recognizing difficulties associated with continuous HBPMs in older individuals with frailty or cognitive decline is important. The next step should consider providing individuals with support to continue HBPM.
As with previous studies that rely on participant contributions to data, this study contains some limitations. First, selection bias is possible. As participants in the NOSE study were recruited as part of an HBPM promotion project, health-conscious people may have been disproportionally included, even though recruitment was conducted by researchers visiting residential activity places. Nose Town is a sparsely populated town in the suburbs of Osaka Prefecture, Japan. Therefore, caution should be exercised when generalizing the results. Second, HBP records were handwritten. Even if HBP was measured, it may not have been recorded. However, this reflects the reality of HBPM and its habitual recording. Third, the resumption of HBPM in the discontinuation group was not considered. The presence of individuals who temporarily discontinued and resumed measurements may have blurred the distinction between continuation and discontinuation. However, we believe that this did not interfere with the findings of the present study. Further studies are required to determine the factors that may lead to resumption of HBPM.
In conclusion, among community-dwelling older adults, female sex, smoking history, lack of exercise, cognitive decline, and frailty were identified as factors influencing HBPM discontinuation. Continued HBPM is important for early detection and management of hypertension with or without antihypertensive medication. Healthcare professionals may be able to promote the continuation of HBPM by providing support to these individuals and by considering the factors associated with HBPM discontinuation which are clarified in the present study.
ACKNOWLEDGEMENTS
We sincerely appreciate all NOSE study participants for their kind cooperation. We are grateful to all relevant members of the Nose Town Office staff, and the Osaka University Graduate School staff, especially Mio Kubo, Keigo Kobayashi, Motoko Nogami, Werayuth Srithumsuk, Nonglak Klinpudtan, Yuya Akagi, Haruna Kikuchi, Yuka Fukata, Minori Eguchi, Ayano Tamura, Yurie Maeyama, Yuka Tachibana, Toshiki Mizuno, Tomoko Yano, Mariko Hosokawa, Yuka Yokoyama, Riko Kinjo, Chihiro Morioka, Natsumi Fujiwara, Ayaka Hiratsuka, Kaoru Hatta, Fang Wen, Yaya Li, and Masaki Isaka. We would like to thank Editage (www.editage.jp) for English language editing.
Conflicts of interest
This study was supported by the Top-Z Research Grant from OMRON HEALTHCARE Co., Ltd. T.O. and K.A. are consultants of OMRON HEALTHCARE Co., Ltd.
Supplementary Material
Supplementary Material
Footnotes
Abbreviations: BP, blood pressure; CVD, cardiovascular diseases; HBP, home blood pressure; HBPM, home blood pressure measurement; MoCA-J, the Japanese version of the Montreal Cognitive Assessment
Supplemental digital content is available for this article.
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