Hypertension in Elderly Patients

Essentials

• The treatment of hypertension in an elderly patient (using a diuretic, and additionally, if required, an ACE inhibitor as drug therapy) is beneficial. The incidence of stroke is reduced and both cardiac and overall mortality are reduced by blood pressure medication when the systolic pressure is lowered below the level 150 mmHg Pharmacotherapy for Hypertension in the Elderly.
• Other concomitant illnesses, functional capacity and degree of frailty aftect the treatment decision and choice of pharaceutical(s).
  • In an elderly patient in good condition the treatment goal is in general comparable to that used for younger patients.
  • In a frail patient (age-related frailty syndrome, see Assessment of Functional Capacity in the Elderly), higher blood pressure levels may be accepted in the treatment of blood pressure. In these patients one should also take into account the possible orthostatic drop in blood pressure.
• The treatment should be introduced cautiously to avoid the risk of disturbances in cerebral circulation and subsequent falls.

Changes related to aging

• On average, systolic blood pressure increases with age whereas diastolic blood pressure starts to decrease after the age of 60 years http://www.dynamed.com/management/hypertension-in-older-adults#TOPIC_IQN_XZT_KGB.
• Isolated systolic hypertension (ISH) is often seen in an elderly person which consitutes a central target for therapy. Associated diseases not only make treatment more difficult but also hamper the comparison of relevant hypertension treatment studies.
• Treatment reduces, in particular, the incidence of stroke and heart failure. The effect on coronary heart disease is smaller. Treatment initiated before the onset of old age may also prevent the incidence of memory diseases. This benefit might be dependent upon the drug choice.
• The following factors may make the treatment of hypertension more dififcult:
  • non-steroidal anti-inflammatory drugs reduce the efficacy of antihypertensive agents and may further damage the kidneys in renal disease
  • renovascular hypertension is difficult to normalize without compromising renal function.
• A very wide pulse pressure may indicate aortic regurgitation.

Diagnosis

• A small part of the elderly have pseudohypertension where atherosclerotic arteries do not compress under the cuff, resulting in falsely high readings http://www.dynamed.com/approach-to/high-blood-pressure-differential-diagnosis#PSEUDOHYPERTENSION. It may be difficult to recognize this condition. Pseudohypertension may be clinically suspected and reduction of medication tried, if no target-organ damage associated with elevated blood pressure can be detected in an elderly person and the strive for achieving recommended blood pressure level causes dizziness or falls.
• "White coat" hypertension is also a common phenomenonhttp://www.dynamed.com/approach-to/high-blood-pressure-differential-diagnosis#BACKGROUND_WHITE_COAT_HYPERTENSION. Home or 24-hour measurements are warranted.
• In order to diagnose orthostatic hypotension, blood pressure must also always be measured with the patient standing up Brief Orthostatic Test; an asymptomatic drop of systolic pressure up to 20 mmHg is common and acceptable http://www.dynamed.com/condition/orthostatic-hypotension-and-orthostatic-syncope#DEFINITIONS.
• Coexisting factors that may reduce blood pressure include:
  • parkinsonism and its medication
  • psychiatric medication, particularly antipsychotics
  • diabetic neuropathy
  • nitrates
  • certain medications used to treat prostatic hyperplasia.

Treatment

Pharmacotherapy

• Life style modifications alone usually do not lower blood pressure in an elderly patient; those among the elderly who have developed illnesses related to lifestyle have already deceased, and the large arteries have lost their elasticity with increasing years. Excessive use of salt should, however, be addressed.http://www.dynamed.com/management/hypertension-in-older-adults#GUID-D09DEA0A-E7E1-4BE5-9AA9-9CEF97C2B756
• Other concomitant illnesses and level of frailty affect the choice of antihypertensive medication. The treatment should be initiated cautiously with a small dose which is increased slowly. The target is not always achieved but even a small reduction in blood pressure is beneficial.
• Orthostatic hypotension is common and may necessitate smaller drug dosagehttp://www.dynamed.com/condition/orthostatic-hypotension-and-orthostatic-syncope#MEDICATIONS.
  • The patient should be advised to get out of bed slowly, and to recognize the symptoms of presyncope.
  • Muscle and balance exercises are beneficial also for other reasons.
  • Good management of blood pressure may also decrease orthostatic tendency.
• A low-dose diuretic is often the first line drug and, if needed, it may be combined with an ACE inhibitor or an angiotensin-receptor (ATR) blocker (particularly if the patient suffers from a cough as an adverse effect to an ACE inhibitor). A calcium-channel blocker is also a good alternative as the initial drug. Combination therapy is started according to response. http://www.dynamed.com/management/hypertension-in-older-adults#GUID-A6BD5D27-587B-4495-8043-46A7F5784766
• A small dose of a thiazide may be sufficient for blood pressure reduction.
  • Excessive dose of a diuretic should be avoided especially in patients small in size.
• If the patient also has diabetes, coronary heart disease or heart failure, a diuretic alone will not be sufficient.
  • A combination of an ACE inhibitor or an ATR blocker with a low-dose diuretic is effective in blood pressure reduction.
  • An ACE inhibitor or an ATR blocker should not be combined with a potassium-sparing diuretic (risk of hyperkalaemia). A combination product should be prescribed instead. A possible exception is the combination of an ACE inhibitor and spironolactone in the treatment of heart failure.
  • Combinations with low dosages are to be preferred.
• Calcium-channel blockers may be used. Concomitant use with a diuretic is possible but may cause hypovolaemia.
• Especially calcium-channel blockers, ACE inhibitors and ATR blockers may be taken in the evening. By doing so, also the possible swelling of the ankles induced by a calcium-channel blocker may disturb the patient less.
• Beta-blockers are not recommended as first-line drugshttp://www.dynamed.com/management/hypertension-in-older-adults#BETA_BLOCKERS.
  • Their efficacy may be improved with the addition of a vasodilating calcium-channel blocker; however, this combination may lead to orthostatic problems as the beta-blocker prevents the required increase in heart rate.
  • A beta-blocker is indicated in coronary heart disease and chronic heart failure.
• An ACE inhibitorhttp://www.dynamed.com/management/hypertension-in-older-adults#ANGIOTENSIN_CONVERTING_ENZYME__ACE__INHIBITORS or an ATR blockerhttp://www.dynamed.com/management/hypertension-in-older-adults#ANGIOTENSIN_RECEPTOR_BLOCKERS__ARBS_ is indicated if the patient has coexisting chronic heart failure, history of myocardial infarction or type 2 diabetes.
  • The monitoring of renal function is important (plasma creatinine, potassium, sodium).
  • A slight increase in the concentration of plasma creatinine does not usually prevent the use of an ACE inhibitor or ATR blocker (provided that the rise in creatinine concentration remains below 30% over baseline during the first 2 months and no hyperkalaemia develops).