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
J Am Coll Cardiol 2011;57:xxx–xx.
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
J Am Coll Cardiol 2011;57:xxx–xx.
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.
J Am Coll Cardiol 2011;57:xxx–xx.
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
J Am Coll Cardiol 2011;57:xxx–xx.
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)
J Am Coll Cardiol 2011;57:xxx–xx.
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
J Am Coll Cardiol 2011;57:xxx–xx.
Lifestyle Modification
J Am Coll Cardiol 2011;57:xxx–xx.
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
J Am Coll Cardiol 2011;57:xxx–xx.
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
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
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