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9 Clinical Evaluation of the Elderly Hypertensive

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9 Clinical Evaluation of the Elderly Hypertensive Chapter 9 / Clinical Evaluation 135 9 Clinical Evaluation of the Elderly Hypertensive L. Michael Prisant, MD, FACC, FACP and Thomas W. Jackson, MD CONTENTS MEASUREMENT OF BLOOD PRESSURE AND CONFIRMATION EVALUATION CONSIDERATIONS HISTORY PHYSICAL EXAMINATION INTEGRATION OF INFORMATION REFERENCES MEASUREMENT OF BLOOD PRESSURE AND CONFIRMATION When confronted with an elevation in blood pressure (BP) in an eld- erly patient, additional measurements are necessary because of increased variability in older persons possibly caused by impaired baroreceptor sensitivity (Fig. 1) (1). In addition to lability of BP, there should be consideration given to the presence of an auscultatory gap (2), orthos- tatic hypotension (3), and pseudohypertension (4). Orthostatic hypertension increases with aging and hypertension and is associated with impairment of baroceptor sensitivity (5). Among eld- erly persons with isolated systolic hypertension, a systolic decline of 20 mmHg or greater was observed in 17.3% of subjects at 1 or 3 minutes after standing (Fig. 2) (3). After a high-carbohydrate meal, supine BP From: Clinical Hypertension and Vascular Diseases: Hypertension in the Elderly Edited by: L. M. Prisant © Humana Press Inc., Totowa, NJ 135 136 Hypertension in the Elderly Fig. 1. Variability of blood pressure. Both the upper panel (women) and lower panel (men) show the increasing blood pressure with increasing standard devia- tion with aging. (Data from ref. 1.) declines, and heart rate increases without an increase in plasma nore- pinephrine levels (6). Standing postmeal ingestion magnifies the BP decline (7). In addition to the risk of falls and fractures, the risk of vascular death is increased (8). The quality of BP measurement is of prime importance for the initial diagnosis and the adjustment of medication (9). For the diagnosis of systemic hypertension, the initial set of sitting BP measurements should occur after 5 minutes of rest and the abstinence of both caffeine and tobacco for 30 minutes. BP should be measured in nontalking patients seated with their back supported and their legs uncrossed. Also, the arm should be bared and supported at heart level. The use of a mercury sphygmomanometer remains the gold standard for routine determina- tion of BP (10). Chapter 9 / Clinical Evaluation 137 Fig. 2. Prevalence of standing systolic blood pressure decline of 20 mmHg or greater. The prevalence of a decline in systolic blood pressure at 1 and 3 minutes increase with higher levels of systolic blood pressure. (Data from ref. 3.) Palpation of the radial artery for the initial cuff inflation will help determine the level of systolic BP. This will avoid unnecessary cuff pressure that might cause pain and the potential underestimation of sys- tolic blood pressure (SBP) that could occur in the presence of an auscul- tatory gap. Not recognizing an auscultatory gap can result in an underestimation of SBP or an overestimation of diastolic blood pressure (DBP). An auscultatory gap is associated with older age, female gender, increased arterial stiffness, and carotid atherosclerotic plaque (11). If the pulseless radial or brachial artery is palpable after ipsilateral occlusion by the cuff, then the patient is described as “Osler positive,” which was a sign of pseudohypertension caused by atherosclerosis (12,13). Pseudohypertension is an elevation in cuff measurement with a normal intra-arterial measurement; thus, the implication of an Osler- positive patient is that the patient is receiving inappropriate treatment (13). However, despite a higher cuff pressure of +15.8/+16.4 mmHg in Osler-positive vs –3.0/+5.3 mmHg in Osler-negative patients, most subjects in this study had SBP measurements greater than 140 mmHg. Another study of geriatric patients identified a prevalence of 11% of Osler-positive patients of 205 screened (14). When Osler-positive and - negative patients were compared with intra-arterial measurements, there was no significant difference in BP. Furthermore, Osler’s maneuver did not predict the presence or absence of pseudohypertension (14). The failure to use a large cuff in an obese patient is another cause of pseudohypertension. Auscultation should be performed with the bell of the stethoscope lightly applied over the brachial artery because Korotkoff sounds are 138 Hypertension in the Elderly low pitched (9). BP measurements are recorded to the nearest 2 mmHg. A good procedure is to perform three measurements and take the average of the last two measurements as the value for that visit. Three visits with a total of six measurements are required to diagnose systemic hyperten- sion (15). Before the initiation of drug therapy, there should be a determination whether postural changes are present. Patients with symptoms of lightheadedness or dizziness; patients taking certain medications, includ- ing antipsychotic medications, antiparkinsonian drugs, α1-blockers, diuretics, and nitrates; and patients with Parkinson’s disease and dia- betes mellitus with autonomic insufficiency need their BP and heart rate measured in the supine position and standing after 1 and 3 minutes. Measurement of BP in the contralateral arm, which is lower, suggests subclavian stenosis. EVALUATION CONSIDERATIONS The assessment of older patients is more complex than for younger patients. A lifetime history is likely to require more time. The reported details may not be as accurate, even if dementia is not present. In addi- tion, altered vision and hearing can present difficulties for the examiner. Believing a symptom is caused by aging, the patient if asked directly may not acknowledge the symptom. Also, the manifestations of a dis- ease may differ in older patients. An assessment of mental status to screen for dementia on initial examination can provide a baseline and provide important information regarding the ability of a patient to follow a medical regimen. The history of older patients should be verified with a family member. Discrepancies in the history often point to dementia. Failure to verify the history can impede the accuracy of diagnosis. HISTORY The purpose of the history is to determine potential symptoms asso- ciated with or suggesting causes of hypertension, evaluate the presence of target organ damage, determine other cardiovascular risk factors, assess concomitant diseases that might interfere with the treatment of hypertension, seek clues suggestive of secondary hypertension, cata- logue all medications used (including over-the-counter medications and herbal remedies), assess resources, assess mental status, and determine general ability to implement the activities of daily living (4,15–17). Specific questions may provide important diagnostic clues (16). The duration and ease of hypertension control are important. For instance, a long history of hypertension that has been well controlled and is now Chapter 9 / Clinical Evaluation 139 Fig. 3. Prevalence of different secondary causes of hypertension in patients 18 years or older. There was an increased prevalence of renovascular hypertension, renal insufficiency, and hypothyroidism with increasing age. (Data from ref. 18.) uncontrolled suggests superimposed secondary hypertension, an inter- fering substance (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], ethanol), or noncompliance (possibly because of finances or dementia). Essential hypertension accounts for most cases of hypertension in the elderly (18). The three most common secondary causes of hypertension are chronic renal insufficiency, hypothyroidism, and renovascular hyper- tension (Fig. 3). The abrupt onset of severe hypertension associated with declining renal function and recurrent pulmonary edema suggests reno- vascular hypertension (19–21). Generally, hypertension is asymptomatic. Symptoms caused by sec- ondary hypertension include (a) headaches, pallor, and diaphoresis (pheochromocytoma); (b) weight loss, tremor, anxiety, tachycardia, fatigue, weakness (hyperthyroidism); (c) confusion, anorexia, weak- ness, myalgias, constipation, depression (hypothyroidism); (d) urinary frequency, nocturia, hematuria, fatigue (renal parenchymal disease); and (e) muscle cramps, muscle weakness, nocturia, hypokalemia (pri- mary aldosteronism). Symptoms secondary to diabetes and hypertensive target organ dam- age, ischemic heart disease, heart failure, cerebrovascular disease, aortic and peripheral vascular disease, renal failure, and retinal disease must be determined to choose the most appropriate initial antihypertensive drug. 140 Hypertension in the Elderly Vascular symptoms of exertional fatigue, dyspnea, orthopnea, edema, angina, palpitations, claudication, transient ischemic attacks, and syn- cope need to be evaluated in terms of daily activities. Heart failure, either systolic or diastolic, and atrial fibrillation are common in the elderly (see Chapter 12). Some patients experience postprandial hypotension asso- ciated with either dizziness or fatigue. Patients should be asked about side effects of medications previously taken as well as allergies. It is wise to have the patient bring all medica- tions to the clinic, including over-the-counter medications and herbal remedies. NSAIDs precipitate heart failure and interfere with the treat- ment of hypertension. Venlafaxine raises BP also. Quantitation of alco- hol ingestion is important because excessive consumption increases BP. Long-standing tobacco use, vascular events (including myocardial inf- arction, strokes, and claudication), and renal insufficiency increase the likelihood of
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