hypertension in the elderly

THE RISE AND FALL:Hypertension in the Elderly

Marc Evans M. Abat, MD, FPCP, FPCGM

Internal Medicine-Geriatric Medicine

Head, Center for Healthy Aging, The Medical City

Consultant, Philippine General Hospital, Manila Doctors Hospital, St. Luke’s Medical Center

Issues to Address

• Epidemiology of Hypertension in the Elderly

• Diagnosis of Hypertension: Any Difference for the Elderly?

• Treatment Considerations for the Elderly?

• Benefits of Treatment?

• Which Drugs to Choose?

EPIDEMIOLOGY OF HYPERTENSION IN THE ELDERLY

Top 10 Leading Causes of Mortality

MORTALITY: TEN (10) LEADING CAUSES, NUMBER AND RATE/100,000 POPULATION

CAUSES5-Year Average

(2001-2005)2006*

Number Rate Number Rate

1. Diseases of the Heart 69,741 85.5 83,081 95.5

2. Diseases of the Vascular System 52,106 64.0 55,466 63.8

3. Malignant Neoplasms 39,634 48.6 43,043 49.5

4. Accidents** 33,650 41.4 36,162 41.6

5. Pneumonia 33,764 41.5 34,958 40.2

6. Tuberculosis, all forms 27,017 33.2 25,860 29.7

7. Chronic lower respiratory diseases 19,024 23.3 21,216 24.4

8. Diabetes Mellitus 15,123 18.5 20,239 23.3

9.Certain conditions originating in the perinatal period

13,931 17.2 12,334 14.2

10. Nephritis, nephrotic syndromeand nephrosis

9,785 12.0 11,981 13.8

MORBIDITY: 10 Leading Causes, Number and Rate

Diseases5-Year Average (1955-

1959)2005

Number Rate Number Rate

1. Acute Lower Respiratory Tract Infection and Pneumonia

694,209 884.6 690,566 809.9

2. Bronchitis/Bronchiolitis 669,800 854.7 616,041 722.5

3. Acute watery diarrhea 726,211 928.3 603,287 707.6

4. Influenza 459,624 587.0 406,237 476.5

5. Hypertension 314,175 400.5 382,662 448.8

6. TB Respiratory 109,369 139.7 114,360 134.1

7. Diseases of the Heart 43,945 56.1 43,898 51.5

8. Malaria 35,970 46.1 36,090 42.3

9. Chicken Pox 79,236 41.1 30,063 36.3

10. Dengue fever 15,383 19.6 20,107 23.6

Prevalence of Hypertension

0

10

20

30

40

50

60

70

50-5960-69

≥70

Pe

rce

nt

Pre

vale

nce

Wit

hin

Gro

up

Age Group

Males

Females

N=3901 patientsPJC Vol. 35, No.1January - June 2007

PhilHealth-Reimbursed Hospitalizations for Hypertension 2002-2005

0 20 40 60

all HPN-related diagnosis

Hypertensive Heart or RenalDisease

Other Definite Consequences

60-79

80-100

N=444528 admissions

BMC Health Services Research 2008, 8:161

Risk Factors for Hypertension in the Elderly

• Agevery important risk factor

Age-Related Changes

Gradual elongation and stiffening of the aortic wall

Increased luminal diameter of the aortaEndothelial cells enlarge, become

irregular in shape size and contourMedial hypertrophySubintimal increase in collagen, smooth

muscle and calcificationSodium and intravascular volume

responsiveness of blood pressure with aging

Noncompliant older aorta is less able to buffer pulsatile output of the heart

Decreased β-adrenergic (vasodilator)Suppression of RAS, decreased renin

euvolemic elderlyDecreased nitric oxide productionAutonomic dysfunction

VasoconstrictionLability of BP response

Other Risk Factors

Hypertension 2006;47;403-409;

Odds ratio

prehypertension 3.5

Current alcohol drinker 1.2

overweight 1.5

Obesity 1.9

Parental history of HPN 1.2

Parental history of DM 1.3

Diabetes mellitus 2.3

microalbuminuria 2.1

macroalbuminuria 4.5

Insulin resistance 1.4-2.7

Insulin levels 1.4-2.0

hypertriglyceridemia 1.3

DIAGNOSIS OF HYPERTENSION: ANY DIFFERENCE FOR THE ELDERLY?

Joint National Commission 7

SBP DBP

Normal <120 and <80

Prehypertension 120-139

or

80-89

Hypertension stage 1 140-159 90-99

Hypertension stage 2 ≥160 ≥100

Diagnosis

• Taken on at least 3 BP measurements, on 2 or more office visits

• Taken after resting for at least 5 minutes

• Proper equipment and instrumentation

J Am Coll Cardiol 2011;57:xxx–xx.

Correct Cuff Sizes

2005, RNAO

Correct Positioning

2005, RNAO

White Coat Hypertension

• Persistent in-office BP elevations with no evidence of end-organ damage

• Out-of-office BP < 140/90

• Intermittent ambulatory BP monitoring may be more appropriate for diagnosis


Pseudohypertension

• Sclerotic, calcified arteries causing non-compressibility

• Suspected in those with– Persistent BP elevation

– No end-organ damage

– Symptoms of overtreatment

• May be screened by the “Osler Maneuver”

• Intraarterial BP measurement


Auscultatory Gap

• Disappearance of the Korotkoff sounds between Phase 2-3

• May be 10-60 mmHg

• Related to arterial stiffness

Unawareness of this phenomenon may lead to an underestimation of the true systolic blood pressure

Measure the palpatory blood pressure first then measure the auscultatory

blood pressure starting at a level above the previous reading.


Isolated Systolic Hypertension

N Engl J Med 2007;357:789-96.

Other Diagnostic Considerations

• BP determination in sitting and standing positions

• Detailed Medical History and Physical Examination

– Medication Review

– Dietary Review

– Tobacco, alcohol and other substance abuse

Work-Up

• To assess target organ damage

– urinalysis

– BUN, creatinine, electrolytes

– Lipid profile

– FBS and possibly HgbA1C

– ECG

• Other labs to rule out secondary causes


Secondary Hypertension

• Sleep apnea

• Drug-induced

• Chronic kidney disease

• Primary aldosteronism

• Renovascular disease

• Chronic steroid therapy or Cushing’s syndrome

• Pheochromocytoma

• Coarctation of the aorta

• Thyroid or parathyroid disease

TREATMENT CONSIDERATIONS FOR THE ELDERLY?

The Geriatric Syndromes

dementia inappropriate prescribing of medications

osteoporosis

depression incontinence sensory alterations including hearing

and visual impairment

delirium iatrogenic problems immobility and

gait disturbances

falls failure to thrive

pressure ulcers sleep disorders

Target Organ Damage/Compelling Indications

• Cerebrovascular disease • Dementia• CAD • LVH and heart failure• cardiac rhythm disorders (atrial fibrillation [AF] and

sudden death)• aortic and peripheral arterial disease• CKD • ophthalmologic disorders • Diabetes mellitus• quality of life (QoL) issues (e.g. sexual function)


Therapeutic Goals

• Less than 140 mm Hg systolic and/or 90 mm Hg diastolic

– Uncomplicated hypertension

– Healthy elderly

– <80 years old

• For those >80 years old, or frail older patients, targets are unclear


Lifestyle Modification


The Difficult Patient

• Unable to bring down the blood pressure despite > 4 drugs

• Adverse reactions (e.g. falls)

• Diastolic blood pressure goes down to <65 mm Hg

may have to settle for a higher BP level control


Figure 1. Percentage of (a) all-cause death and (b) CV death by DBP strata of 10 mm Hg.

Protogerou A D et al. Hypertension 2007;50:172-180

Diastolic Blood Pressure

WHICH DRUGS TO CHOOSE?

Comparison of blood pressure lowering regimens against placebo or

less intensive control.

BMJ 2008;336:1121-1123

Blood pressure lowering regimens based on different drug classes for the

outcome total major cardiovascular events and age groups <65 versus ≥65.

BMJ 2008;336:1121-1123

Sublingual Antihypertensives

• May lead to sudden and drastic BP drops

• Complications

– Cerebral ischemia

– Myocardial ischemia

– Falls

BENEFITS OF TREATMENT?

Subgroup analysis: FEVER Study

European Heart Journal (2011) 32, 1500–1508

Strict vs. Moderate Systolic BP Control

Hypertension. 2010;56:196-202;

BP Nadir by Age and Risk of Events

Am J Med. 2010 August ; 123(8): 719–726

hypertension in the elderly

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