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Hypertension in the Elderly: Some Practical Considerations

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Hypertension in the Elderly: Some Practical Considerations REVIEW KASHIF N. CHAUDHRY, MD PATRICIA CHAVEZ, MD JERZY GASOWSKI, MD a Mount Sinai School of Medicine, St. Luke’s-Roosevelt Hospital Center, Department of Internal Medicine and Englewood Hospital Program, Columbia University College of Physi- Gerontology, Jagiellonian University, Englewood, NJ cians and Surgeons, New York, NY Krakow, Poland TOMASZ GRODZICKI, MD b FRANZ H. MESSERLI, MD, FACC, FACP c Department of Internal Medicine and St. Luke’s-Roosevelt Hospital Center, Columbia Gerontology, Jagiellonian University, University College of Physicians and Surgeons, Krakow, Poland New York, NY Hypertension in the elderly: Some practical considerations ■■ ABSTRACT he management of hypertension has ad- Tvanced significantly in the last few decades. Data from randomized controlled trials suggest that But the race for more effective means to control treating hypertension in the elderly, including octogenar- this epidemic and its associated complications ians, may substantially reduce the risk of cardiovascular is far from won. A high percentage of patients disease and death. However, treatment remains challeng- in the United States have hypertension that ing because of comorbidities and aging-related changes. is uncontrolled. Most of these belong to the most rapidly growing demographic group in the We present common case scenarios encountered while United States, ie, the elderly. managing elderly patients with hypertension, including It is estimated that more than 70% of med- secondary hypertension, adverse effects of drugs, labile ical practice will be directed to geriatric needs hypertension, orthostatic hypotension, and dementia. in the coming years. It is therefore very im- ■■ portant for clinicians to be comfortable with KEY POINTS managing hypertension in the elderly. Therapy should be considered in all aging hypertensive patients, even the very elderly (> 80 years old). ■ A GROWING PROBLEM IN AN AGING POPULATION Most antihypertensive drugs can be used as first-line Between 1980 and 2009, the US population treatment in the absence of a compelling indication for a age 65 and older increased from 25.6 million to specific class, with the possible exception of alpha-block- 39.6 million, of which 42% are men and 58% ers and beta-blockers. women.1 This number is expected to reach 75 million by the year 2040. People over 85 years An initial goal of less than 140/90 mm Hg is reasonable of age are the fastest growing subset of the US in elderly patients, and an achieved systolic blood pres- population.2 As many as 50% of people who sure of 140 to 145 mm Hg is acceptable in octogenarians. were born recently in countries such as the United States, the United Kingdom, France, Denmark, and Japan will live to celebrate Start with low doses; titrate upward slowly; and monitor their 100th birthday.3 closely for adverse effects. According to the Framingham Heart Study, by age 60 approximately 60% of the popula- Thiazide diuretics should be used with caution in the tion develops hypertension, and by 70 years elderly because of the risk of hyponatremia. about 65% of men and about 75% of women have the disease. In the same study, 90% of a Dr. Gasowski has disclosed teaching and speaking for the Servier and Zentiva companies. those who were normotensive at age 55 went b Dr. Grodzicki has disclosed teaching and speaking for the Servier and Novartis companies. on to develop hypertension. The elderly also c Dr. Messerli has disclosed consulting for Novartis, Daiichi Sankyo, Pfizer, Takeda, Abbott, PharmApprove, Gilead, Servier, Bayer, and Medtronic and receiving grant support from Forest and are more likely to suffer from the complica- Boehringer Ingelheim. tions of hypertension and are more likely to doi:10.3949/ccjm.79a.12017 have uncontrolled disease. 694 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 79 • NUMBER 10 OCTOBER 2012 Downloaded from www.ccjm.org on September 26, 2021. For personal use only. All other uses require permission. CHAUDHRY AND COLLEAGUES Compared with younger patients with simi- rived from randomized controlled trials for lar blood pressure, elderly hypertensive patients any population, let alone the elderly. The have lower cardiac output, higher peripheral generally recommended blood pressure goal resistance, wider pulse pressure, lower intra- of 140/90 mm Hg for elderly hypertensive pa- vascular volume, and lower renal blood flow.4 tients is based on expert opinion. These age-related pathophysiologic differences Moreover, it is unclear if the same target must be considered when treating antihyper- should apply to octogenarians. According to a tension in the elderly. 2011 American College of Cardiology/Ameri- can Heart Association (ACC/AHA) expert ■ IS TREATING THE ELDERLY BENEFICIAL? consensus report,8 an achieved systolic blood pressure of 140 to 145 mm Hg, if tolerated, Most elderly hypertensive patients have mul- can be acceptable in this age group. tiple comorbidities, which tremendously affect An orthostatic decline in blood pressure the management of their hypertension. They accompanies advanced age and is an inevi- are also more likely than younger patients to table adverse effect of some antihypertensive have resistant hypertension and to need mul- drugs. Accordingly, systolic blood pressure tiple drugs to control their blood pressure. In lower than 130 and diastolic blood pressure the process, these frail patients are exposed to lower than 70 mm Hg are best avoided in oc- a host of drug-related adverse effects. Thus, it togenarians.8 Therefore, when hypertension is relevant to question the net benefit of treat- is complicated by coexisting conditions that ment in this age group. require a specific blood pressure goal, it would Many studies have indeed shown that seem reasonable to not pursue the lower target treating hypertension reduces the risk of stroke as aggressively in octogenarians as in elderly and other adverse cardiovascular events. A patients under age 80. decade ago, Staessen et al,5 in a meta-analysis Having stated the limitations in the qual- of more than 15,000 patients between ages ity of data at hand—largely observational—it 62 and 76, showed that treating isolated sys- is relevant to mention the Systolic Blood Pres- tolic hypertension substantially reduced mor- sure Intervention trial (SPRINT).9 This ongo- About 60% of bidity and mortality rates. Moreover, a 2011 ing randomized, multicenter trial, launched by the population meta-analysis of randomized controlled trials the National Institutes of Health, is assessing in hypertensive patients age 75 and over also whether maintaining blood pressure levels develops concluded that treatment reduced cardiovas- lower than current recommendations further hypertension cular morbidity and mortality rates and the in- reduces the risk of cardiovascular and kidney cidence of heart failure, even though the total diseases or, in the SPRINT-MIND substudy, of by age 60 mortality rate was not affected.6 age-related cognitive decline, regardless of the Opinion on treating the very elderly (≥ type of antihypertensive drug taken. Initially 80 years of age) was divided until the results planning to enroll close to 10,000 participants of the Hypertension in the Very Elderly trial over the age of 55 without specifying any age- (HYVET)7 came out in 2008. This study doc- group ranges, the investigators later decided umented major benefits of treatment in the to conduct a substudy called SPRINT Senior very elderly age group as well. that will enroll about 1,750 participants over The consensus, therefore, is that it is ap- the age of 75 to determine whether a lower propriate, even imperative, to treat elderly hy- blood pressure range will have the same ben- pertensive patients (with some cautions—see eficial effects in older adults. the sections that follow). Given the limitations in the quality and applicability of published data (coming from ■ GOAL OF TREATMENT IN THE ELDERLY small, nonrandomized studies with no long- term follow-up), SPRINT is expected to pro- Targets for blood pressure management have vide the evidence needed to support standard been based primarily on observational data in vs aggressive hypertension control among the middle-aged patients. There is no such thing elderly. The trial is projected to run until late as an ideal blood pressure that has been de- 2018. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 79 • NUMBER 10 OCTOBER 2012 695 Downloaded from www.ccjm.org on September 26, 2021. For personal use only. All other uses require permission. HYPERTENSION IN THE ELDERLY TABLE 1 to lower blood pressure more in older adults than in younger adults. In the DASH trial,12 Compelling indications for specific classes systolic blood pressure decreased by 8.1 mm of antihypertensive drugs as initial drug therapy Hg with sodium restriction in hypertensive patients age 55 to 76 years, compared with 4.8 Heart failure mm Hg for adults aged 23 to 41 years. In the Chlorthalidone (Hygroton), indapamide (Lozol), beta-blockers, angioten- Trial of Nonpharmacologic Interventions in sin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers 13 (ARBs), calcium channel blockers, aldosterone receptor antagonists the Elderly (TONE), in people ages 60 to 80 who were randomized to reduce their salt in- After myocardial infarction take, urinary sodium excretion was 40 mmol/ Beta-blockers, ACE inhibitors, ARBs, aldosterone receptor antagonists, day lower and blood pressure was 4.3/2.0 mm nondihydropyridine calcium channel blockers Hg lower than in a group that received
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