hypertension in the geriatric patient: review and update · •pseudohypertension •white coat...

copy2015 MFMER | slide-1

Hypertension in the Geriatric Patient Review and Update

Donna Miller MD Senior Associate Consultant Division of Hospital Internal Medicine Instructor in Medicine

CAPA Annual Conference October 24 2015


Disclosures

bull I have no relevant financial relationships to disclose


Objectives

bull Identify unique considerations related to blood pressure in geriatric patients

bull Restate the evidence base supporting guidelines for blood pressure targets in healthy older adults

bull Recognize the importance of function in the approach to hypertension (HTN) management in geriatric patients


Overview

bull General hypertension principles

bull Evidence and treatment guidelines

bull Orthostatic hypotension

bull Frailty

bull Cognition


The Heterogeneity of Aging

85 year old male with HTN

bull Robust

bull Few comorbidities

bull Cognition intact

bull Independent function


bull Frail

bull Multiple comorbidities

bull Cognitive impairment

bull Functional dependence

These are two very different patientshellip

Growing evidence would suggest that we approach

hypertension differently in these two patients


Case 1 ldquoIrsquom just here for a check uprdquo

bull Mrs Well is an 81 year old community-dwelling female with knee osteoarthritis and depression Blood pressure on 3 separate occasions has been 16484 15880 and 16284

bull Is this normal aging or pathogenic


Cardiovascular Effects of Aging

bull Stiffer

bull Large vessels less distensible

bull Decreased vascular compliance

bull Slower

bull Baroreceptors less sensitive

bull Increased blood pressure variability



bull 67 community-dwelling older adults have HTN

AHAACC Guideline JACC 2011 Geriatrics Review Syllabus 8th Edition


Blood Pressure J-Shaped Curve

Is this cause or correlation

Sim et alJ Am Coll Cardiol 201464(6)588-597 Denardo et ail Am J Med 2010 Dorresteijn et al Hypertension 2012

Dorresteijn et al Hypertension 20125914-21


Denardo et al Americal Journal of Medicine 2010 123(8)719-726


U-shaped curve appears in the oldest old

bull Observational study in Sweden

bull Age 85 (n=139) age 90 (n=128) age ge 95 (n=81)

bull Systolic blood pressure (SBP) lt1113103120 mmHg correlated with higher mortality

bull Even after controlling for health status

bull Mortality nadir was found at SBP 164 mmHg

Molander J Am Geriatr Soc 561853ndash1859 2008


Consider other factors in HTN ldquodiagnosisrdquo

bull Pseudohypertension

bull White coat hypertension

bull Masked hypertension


bull Renal artery stenosis

bull Obstructive sleep apnea

bull NSAIDs

bull Alcohol

bull Tobacco

bull Steroids

ACCFAHA 2011 Expert Consensus Document on Hypertension in the Elderly





bull Is there literature evidence to support benefit to starting an antihypertensive


HYpertension in the Very Elderly Trial (HYVET)

bull Randomized trial with 3845 patients age gt80

bull Treatment started if SBP gt160 mmHg

bull Indapamide (diuretic)

bull Perindopril (ACE inhibitor) added prn

bull Target BP lt150 mmHg

bull Study terminated due to preliminary results

Beckett et al 2008 NEJM 358(18)1887-1898



bull Results

bull 21 decrease mortality

bull 23 decrease cardiovascular mortality

bull 64 decrease in CHF

bull Non-significant decrease in stroke (p=006)




bull Patients who were excluded

bull Severe CV disease

bull Renal failure

bull Dementia

bull Clinically significant comorbidities



Take Home Point(s)

bull Treat (stage 2) hypertension in healthy community-dwelling older adults

bull Evidence is lacking in sicker older adults


Guidelines andor Consensus Statements

Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE

lt14080 Treat when gt160 Target lt15090

2013 ESH-ESC

140-150

Perhaps lower if robust

140-150

If good physical and mental health

2014 CHEP

lt14090 lt150

2014 JNC8

Treat when SBP gt150 Target lt15090



Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8


Summary lt14090 unless frail lt15090 but not less than 13065


Systolic Blood Pressure Intervention Trial (SPRINT)

bull What is ideal BP target in patients age gt50 with hypertension

Ambrosius et al Clinical Trials 2014 Vol 11(5) 532ndash546

Big Study N=9361

Older patients Average age 68

28 over age 75

Sicker patients 28 CKD

20 CV disease

10 Framingham risk

Functional assessment

Cognition

Gait speed

Average baseline MoCA 229

Average baseline 08 ms



bull Sneak peek at initial results from SPRINT

bull Target SBP 140 (control)

vs

bull Target SBP 120

bull Reduced rates of CV events by almost 33

bull Reduced mortality by almost 25

NIH press release 9112015


Treatment Lifestyle Measures

bull DASH diet

bull Low sodium diet

bull Caution nutrition hyponatremia orthostasis

bull Weight loss in overweightobese

bull Caution muscle loss cachexia

bull Alcohol below maximum recommended levels

Whelton et al JAMA 1998279(11) 839-846


Eat chocolate

bull Flavanols in cocoa increase nitric oxide

bull Meta-analyses of 20 studies n = 856

bull Mean difference SBP -277 mm Hg p=0005

bull Mean difference DBP - 220 mm Hg p=0006

Ried et al Cochrane Review Aug 2012


Treatment Medication Considerations

Medication class Examples Potential Considerations

in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone

Hypokalemiahyponatremia

hyperglycemiaincontinence

Calcium channel block

(dihydropyridine)

Amlodipine

nifedipinefelodipine

Edema

ACE inhibitorARB

Lisinopril

perindopril losartan

Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue

Less sensitive receptors

Not first line




in Older Adults

Alpha blocker Doxazosin

terazosin

BPH (tamsulosin)

Orthostatic hypotension

Avoid

Vasodilators Hydralazine Orthostatic hypotension

Avoid

Central-acting agent Clonidine

methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)

bull General treatment targets

bull Age over 60 lt14090 unless frail

bull Age over 80 lt15090 not less than 13065

bull Consider lifestyle measures (with caution)

bull ldquoStart Low Go Slowrdquo with medications


Case 2 ldquoIrsquove fallen and I canrsquot get uprdquo

bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy Medications include HCTZ 25mg and lisinopril 40mg

bull Vitals T 37 BP 11060 HR 80 RR 18

bull Supine BP 12274 Standing BP 9876

bull Exam Generally well appearance non-diagnostic exam

bull LabsStudies

bull WBC 8 HgB 13 Na 130 BUN 40 Cr 16 Glucose 120

bull UA bland CXR normal ECG suggests LVH


Orthostatic hypotension increases with age

bull Defined as decrease in SBP by 20 mmHg or DBP by 10 mmHg within 3 minutes of standing

Benvenuto and Krakoff J Hypertension Feb 2011


500-1000 cc blood pools

Increase sympathetic tone

Decrease parasympathetic

BP and cardiac output fall

Baroreceptors sense change

Increase heart rate

Increase vascular resistance

Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already

Increase blood pressure

Less reserve to handle changes

in position or fluid status


Orthostatic hypotension was addressed in HYVET methods

bull Exclusion criteria Standing SBP le140 mmHg

bull Mean baseline standing was 168mmHg

bull Only 8-9 had orthostatic hypotension

bull Medications were not increased for those with seated SBP gt150 if standing SBP was lt120


Orthostatic hypotension is associated with worse outcomes

bull Patients with orthostatic hypotension may or may not have symptoms hellip

bull Increased risk

bull Stroke

bull Myocardial infarction

bull Mortality



Orthostatic hypotension is associated with cognitive impairment

Cognitive Status Orthostatic

Hypotension

Normal cognitive function 4

Mild cognitive impairment (MCI) 12

Alzheimer dementia 15

Vascular dementia 22

S Mehrabian et al Journal of the Neurological Sciences 299 (2010) 45ndash48


Orthostatic changes are linked to progression from MCI to dementia

bull Study of community-dwelling adults with MCI

bull In 3 years 30 converted to dementia

bull Positional blood pressure was very dynamic

bull Baseline seated SBP 148 mmHg

bull 70 had gt40mmHg drop (within 15 seconds)

bull SBP generally stabilized by 30 seconds

bull If not twice the risk of dementia at 3 years Hayakawa et al J Am Geriatr Soc 631868ndash1873 2015


Take home point(s)

bull Blood pressure is a dynamic (not static) thing

bull Prevalence of orthostatic hypotension increases with age for multiple reasons

bull We need to think about orthostatic hypotension as it is linked with multiple negative outcomes


Case 3 ldquoIrsquom fine though I have no energyrdquo

bull Miss Step is an 80 year old female with arthritis cataracts CHF (EF normal) dementia and hypertension who lives in a nursing home

bull Meds Acetaminophen amlodipine clonidine donepezil furosemide potassium tramadol

bull Vitals Sitting BP 13872 Standing BP 12664

bull Is she frail

bull Is her blood pressure ldquoat targetrdquo


Frailty Definition

Fried et al J Gerontol A Biol Sci Med Sci 2001

Need ge3 for diagnosis of frailty

bull S-lowness (gait speed)

bull L-ow activity level

bull E-xhaustion

bull W-eight loss (10lbs past year)

bull W-eakness (grip strength)


Low blood pressure in the oldest old and frail is worse than high blood pressure

bull Multiple studies of adults age ge 85

bull Majority with functional dependence

bull Results

bull High SBP was not a risk factor for mortality

bull SBP lt14070 associated with higher mortality

Rastas et al J Am Geriatr Soc 54912ndash918 2006 Bemmel et al Hypertens 2006 24287ndash 292


Tightly treated hypertension is linked to mortality in frail adults

bull PARTAGE study

bull Frail adults (mean age 87) in nursing homes

bull Nearly 60 taking BP meds had SBP lt140

bull ldquoTarget BPrdquo rates only 30 in community

bull Results

bull Mortality increased if SBP was lt130 on combination (ge2 drug) therapy (HR 178)

Benetos et al J Hypertens 201028(1)41-50 Lloyd-Jones et al JAMA 2005294(4)466-472

Benetos et al JAMA Intern Med 2015175 (6)989-995


Gait Speed A Geriatric ldquoVital Signrdquo

Gait Speed Mortality

in Patients with SBPgt140

Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)

Odden et al Arch Intern Med 2012172(15)1162-1168


Timed Up and Go Test

bull Useful for fall riskhellip and hypertension too

Podsiadlo D Richardson S The timed ldquoup amp go A test of basic functional mobility for frail elderly persons JAGS 199139142-148


Take home point(s)

bull Benefit of treating hypertension in older adults may depend on onersquos degree of frailty

bull Gait speed is a quick bedside prognostic tool and may help identify those unlikely to benefit

bull In frail individuals low blood pressure on treatment is associated with worse outcomes


Case 4 ldquoMy memory isnrsquot what it used to berdquo

bull Mr Forgetful is a 90 year old retired pharmacist with mild cognitive impairment hypertension depression and family history of Alzheimerrsquos Routine BP is 14680 with no positional change

bull Medications Amlodipine citalopram fish oil vitamin E vitamin C and gingko

bull He asks you ldquoWouldnrsquot better blood pressure control be good for my brainrdquo


Mid-life hypertension is associated with late-life cognitive impairment

bull Surviving cohort of Honolulu Heart Program (n=3735 mean age 78) underwent cognitive testing 30 years later

bull Results

bull Every 10mmHg increase in mid-life SBP progressively increased risk for late-life cognitive impairment

Launer et al The Honolulu-Asia Aging Study JAMA 19952741846ndash1851


Randomized trials suggest treatment of hypertension is beneficial for cognition

bull Number needed to treat

bull Treatment of 1000 patients for 5 years can prevent 20 cases of dementia

Tzourio et al PROGRESS Group Arch Intern Med 20031631069-1075 Forette et al SYS-EUR Group Arch Intern Med 20021622046-2052

Study Age Follow up Outcome Treatment Control

PROGRESS 64 4 years Cognitive

decline

91 11

SYST-EUR 70 39 years Dementia

diagnosis

33 per

1000

74 per

1000


Association between late-life hypertension and cognitive impairment is unclear

bull Three studies reported no significant effect

bull Seven studies reported a positive effect

bull Three studies reported a U-shaped curve

Qiu et al Lancet Neurol 2005 4 487ndash99


Late-Life Blood Pressure and Cognition

bull Leiden 85 Plus study

bull Followed patients from age 85-90

bull Higher SBP was better

bull Less ADL disability

bull Higher MMSE scores

bull Slower decline in both measures over time

bull Most pronounced in those with high disability Sabayan et al J Am Geriatr Soc 602014ndash2019 2012



bull Cognitively impaired older adults

bull Majority (69) on blood pressure medication

bull Lower BP (SBP lt128) was associated with faster progression of cognitive decline

Mossello et al JAMA Internal Medicine 2015



bull 1540 community-based patients age gt75

bull Higher SBP associated with better cognition

bull Most pronounced in those aged 85 and older with ADL and IADL impairments

Giulia et al J Am Geriatr Soc 631741ndash1748 2015

Tertile Mean BP Hypertension BP med use

Low 12469 61 57

Middle 14480 71 65

High 17994 78 70


Discontinuation of ANtihypertensive Treatment in Elderly People (DANTE) Trial

bull N=385 age gt75 with mild cognitive impairment

bull Baseline BP 14882

bull 60 took ge 2 antihypertensive drugs

bull 45 had orthostatic hypotension

bull Results (at 16 weeks)

bull Increased SBP 7mmHg and DBP 2mmHg

bull No difference in cognition depression functional status or quality of life

Moonen et al JAMA Intern Med 2015175(10)1622-1630


Modifiedupdated from Qiu et al Lancet Neurol 2005 4 487ndash99

Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults

Microvascular disease

White matter disease

Cerebral hypoperfusion

Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation

Cognitive impairment

Dementia

Mortality


Take home point(s)

bull Mid-life hypertension is linked to cognitive decline and dementia in later life

bull Treatment in 60s-70s seems to be beneficial

bull Higher blood pressure in the oldest old seems to be associated with better cognition

bull Especially in the setting of frailty andor MCI


Summary

bull Age associated cardiovascular changes

bull Slower and stiffer

bull ldquoStart low go slowrdquo

bull Evidence and guidelines

bull Most suggest lt14090 over age 60


bull Less guidance on lower limit perhaps 13065


Summary


bull Common clinically significant

bull Frailty

bull SLEWW Gait speed is good indicator

bull Insufficient evidence for BP target in frailty

bull Cognition

bull Treat BP in younger years ldquotoo little too laterdquo


Back to our caseshellip Case 1 Hypertension in robust individuals





Back to our caseshellip Case 2 Orthostatic hypotension

bull Mr Wobble is a 76 year old male with HTN and diet-controlled diabetes who fell after feeling dizzy

bull Meds HCTZ 25 and lisinopril 40

bull Vitals Supine BP 12274 Standing BP 9876

bull LabsStudies Na 130 BUN 40 Cr 16

bull Management


Back to our caseshellip Case 3 Frailty




bull Is she frail



Back to our caseshellip Case 4 Cognitive impairment




him


Conclusion

bull Treat HTN Use FUNCTION as your guide

bull Healthy independent

bull Treat per current guidelines (lt140-15090)

bull Frail comorbidity cognitive impairment

bull Evidence is insufficient to suggest benefit

bull Individualize treatment

bull ldquoPrimum non nocererdquo (first do no harm)


Mayo Clinic Locations


Questions amp Discussion


Disclosures

bull I have no relevant financial relationships to disclose


Objectives





Overview




bull Frailty

bull Cognition




bull Robust





bull Frail













bull Stiffer



bull Slower






























bull NSAIDs

bull Alcohol

bull Tobacco

bull Steroids


















bull Results










bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Objectives





Overview




bull Frailty

bull Cognition




bull Robust





bull Frail













bull Stiffer



bull Slower






























bull NSAIDs

bull Alcohol

bull Tobacco

bull Steroids


















bull Results










bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Overview




bull Frailty

bull Cognition




bull Robust





bull Frail













bull Stiffer



bull Slower






























bull NSAIDs

bull Alcohol

bull Tobacco

bull Steroids


















bull Results










bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion















bull Robust





bull Frail













bull Stiffer



bull Slower






























bull NSAIDs

bull Alcohol

bull Tobacco

bull Steroids


















bull Results










bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion


















bull Stiffer



bull Slower






























bull NSAIDs

bull Alcohol

bull Tobacco

bull Steroids


















bull Results










bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion







































bull NSAIDs

bull Alcohol

bull Tobacco

bull Steroids


















bull Results










bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion




























bull Results










bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion
















bull Renal failure

bull Dementia




Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Take Home Point(s)





Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion














Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8




Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion














Age gt60 Age gt80

2011 ACCAHA

lt14090 140-145 ok in some

No lower than 13065

2011 NICE


2013 ESH-ESC

140-150


140-150


2014 CHEP

lt14090 lt150

2014 JNC8







Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion
















Big Study N=9361


28 over age 75


20 CV disease

10 Framingham risk


Cognition

Gait speed







vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion
















vs

bull Target SBP 120






bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion














bull DASH diet








Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Eat chocolate









in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion















in Older Adults

Thiazide diuretic

HCTZ indapamide

chlorthalidone




(dihydropyridine)

Amlodipine


Edema

ACE inhibitorARB

Lisinopril


Hyperkalemia

Beta blocker

Carvedilol

bisoprolol

nebivolol atenolol

Bradycardia fatigue


Not first line




in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion















in Older Adults


terazosin

BPH (tamsulosin)


Avoid


Avoid


methyldopa

Anticholinergic

Delirium


Avoid


Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Take Home Point(s)












bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion


















bull LabsStudies













Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion






















Increase heart rate


Slower and

Blunted response

Less sensitive and

Slower to respond

Blunted

Stiff already













bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion





















bull Increased risk

bull Stroke


bull Mortality





Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion















Hypotension
















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion






















Take home point(s)









bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion

















bull Is she frail



Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Frailty Definition





bull E-xhaustion







bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion
















bull Results






bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion














bull PARTAGE study




bull Results








Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion
















Faster (gt08ms)

Higher (HR 135)

Slower

No association

No test completed

Lower (HR 038)







Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion

















Take home point(s)












bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion




















bull Results










decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion



















decline

91 11


diagnosis

33 per

1000

74 per

1000





























Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion








































Low 12469 61 57

Middle 14480 71 65

High 17994 78 70













Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion
























Mid-life

Hypertension

Late-life

Low blood pressure

Ischemic insults




Ischemic damage

Atherosclerosis

BP

medications

Circulatory

dysregulation


Dementia

Mortality


Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Take home point(s)






Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Summary









Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion













Summary



bull Frailty



bull Cognition













bull Management






bull Is she frail







him


Conclusion























bull Management






bull Is she frail







him


Conclusion

















bull Is she frail







him


Conclusion

















him


Conclusion













Conclusion












hypertension in the geriatric patient: review and update · •pseudohypertension •white coat...

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