Hypertension in the Elderly: Pocketbook

Hypertension is commonly encountered in the aging population. The third National Health and Nutrition Examination Survey (NHANES III) found that 65% of.
Table of contents

A number of caveats are to be noted concerning whitecoat hypertension. The appropriate evaluation of such patients is demonstrated in Figure If significant 28 target organ damage is present, more intensive treatment is indicated even if a white-coat component is making the office pressure higher than it is out of the office. Figure 16 Rate of major cardiovascular morbid events in the normotensive group and in the groups with white-coat and ambulatory hypertension. Event rate did not differ between the normotensive group A and the group with more restrictively defined white-coat hypertension B: If the patient is truly normotensive 30 out of the office, the diagnosis of hypertension should not be affixed to them, and nor should antihypertensive drug therapy be started.

Rather, such patients should be strongly encouraged to modify harmful lifestyle habits as will be described later and to monitor their blood pressure carefully as some may progress to persistent hypertension. Some investigators and practitioners object to this more conservative approach, noting that all of the data on the risks of hypertension have been based on office readings, and often on only a limited number of them. More long-term follow-up is needed but, at present, out-of-office readings have been shown to be more closely predictive of future risk.

High office readings are not to be disregarded, but they include some with truly high readings who are at increased risk and others with readings that are high because of the white-coat effect who seem to be at little increased risk. Pseudohypertension As noted, the white-coat effect is more common and significant in the elderly than in younger people, and so out-of-office readings should be obtained if possible.

In addition to white-coat hypertension, the elderly may have artifactually elevated pressures by usual indirect cuff measurements because of the increased stiffness of the large arteries, which precludes compression and collapse of the brachial artery. Therefore, the manometer shows much higher pressures in the balloon than are present within the artery, giving rise to pseudohypertension.

It should be suspected if high sphygmomanometer readings are noted but few signs of such severe hypertension are present, and particularly if symptoms of hypotension follow only a modest lowering of pressure with antihypertensive therapy. More accurate estimates of true intra-arterial pressure may be obtained by oscillometric measurements. In the generally healthy population of elderly men and women enrolled in the Systolic Hypertension in the Elderly Program, postural hypotension was found in The prevalence would probably have been higher if the patients had been tested after rising from a supine position.

The only predisposing factor for postural hypotension found in an unselected elderly population was hypertension. As seen in Figure 17, the higher the basal supine systolic blood pressure, the greater the postural fall. Figure 17 Relationship between basal supine systolic BP and postural change in systolic BP for aggregate data from older subjects.

From Lipsitz et al. The two most common in patients with supine or seated hypertension are venous pooling in the legs and autonomic insufficiency. The reductions in baroreceptor sensitivity that often accompany isolated systolic hypertension are mainly related to aging. Postprandial hypotension is related to splanchnic pooling of blood after eating.

As reported by Grodzicki et al. Management Postural and postprandial hypotension must often be treated before the frequently coexisting seated and supine hypertension can be managed Tonkin, A summary of the exacerbating factors, pathophysiology and therapy of postural hypotension is shown in Figure A few additional points deserve emphasis.

Postprandial hypotension is usually ameliorated by smaller meals, perhaps lower in carbohydrate to minimize the rise in insulin that may induce vasodilation. Caffeine does not prevent postprandial hypotension. Those with systolic pressure above and diastolic pressure below 90 mmHg are defined as having isolated systolic hypertension ISH , although in many series ISH is inappropriately reserved only for those with systolic pressure above mmHg. Such evaluation can be accomplished with relative ease and should be part of the initial examination of every newly discovered hypertensive.

The younger the patient and the higher the blood pressure, the more intensive the search for reversible causes should be. Among middle-aged and older patients greater attention should be directed to the overall cardiovascular risk profile, as these populations are more susceptible to immediate catastrophes unless preventive measures are taken.

An area of great importance is sexual dysfunction, often neglected until it arises after antihypertensive therapy is given. Erectile dysfunction, often attributed to 37 antihypertensive drugs, may be present in as many as half of untreated, elderly hypertensive men, and is most likely related to their underlying vascular disease. Physical examination The physical examination should include a careful search for damage to target organs and for features of various reversible causes Table 7.

Funduscopic Only in the optic fundi can small blood vessels be seen with ease, but this requires dilation of the pupil, a procedure that should be more commonly practiced. Keith, Wagener and Barker, in , originally classified the funduscopic changes but mixed two separate vascular changes: A— nonmalignant , generalized arteriolar narrowing and focal constriction; and B— malignant , hemorrhages, hard exudates and cottonwool spots, with or without optic disc swelling Figures 19 and Laboratory data Routine As described in the Sixth Joint National Committee report JNC-6 , for most patients a hematocrit, a urine analysis, an automated blood chemistry glucose, creatinine, electrolytes , a lipid profile total and highdensity lipoprotein cholesterol, triglycerides and an ECG are all of the routine procedures needed.

None of these usually yields abnormal results in the early, uncomplicated phases of essential hypertension, but they should always be obtained for a baseline. Hypertriglyceridemia and, even more threatening, hypercholesterolemia are found more frequently in untreated hypertensives than in normotensives. The prevalence increases with the blood pressure level. The association may, in turn, reflect the quartet of upper body obesity, hyperlipidemia, glucose intolerance and hypertension related to hyperinsulinemia.

Post navigation

Lipoprotein a levels and certain apolipoprotein a isoforms are strong and independent risk factors for coronary disease in hypertensives, so these measurements may be added to the lipid profile. Hyperuricemia is found in up to half of untreated hypertensives and usually reflects underlying nephrosclerosis. Not only is gout more common in hypertensives, but so are 39 Figure 19 a Right eye showing tortuous vessels superotemporal to the optic disc and some microaneurysms close to the fovea, possibly a microvascular occlusion secondary to hypertension, b Fluorescein angiogram in the arteriovenous phase of the same patient, showing the tortuous vessels, microaneurysms and dilated capillaries on the nasal side of the foveal arcade.

There is leakage from and staining of vessels as they cross poorly perfused areas of the retina. A few microaneurysms can be seen at the top of the picture. Incipient renal disease may be heralded by microalbuminuria. Lesser degrees of LVH are identified by echocardiography, but until the recognition of LVH is shown to add independent prognostic information, echocardiography is not recommended as a routine procedure in view of its cost. Figure 21 ECG of a patient with left ventricular hypertrophy. In the presence of symptoms of cerebral ischemia the finding of a carotid bruit indicates the need for carotid ultrasonography in the hope of finding a significant and correctable lesion.

Renal dysfunction is usually first recognized by microalbuminuria, and testing for this may become routine. Usually, additional testing for renal damage is reserved for those with elevated serum creatinine levels. Aortic abdominal aneurysms should be looked for by careful palpation and, if suspected, confirmed by ultrasonography followed by appropriate imaging procedures Figure The one most likely to be found in the elderly is atherosclerotic renovascular disease, particularly when hypertension appears or worsens suddenly and develops on the background of extensive atherosclerotic disease elsewhere.

If the initial screening studies are positive or clinical suspicion is strong, the additional studies should be obtained even if initial studies are negative Vasbinder et al. The recognition of renal vascular disease is particularly important, as appropriate medical therapy may control hypertension and prevent progressive renal damage van Jaarsveld et al. Sleep apnea is more common in hypertensives and may contribute to resistance to therapy Lavie and Hoffstein, The evidence that such treatment is beneficial for the elderly with hypertension is examined next. In particular, the reduction in CHD was almost twice that seen in the younger patients, which is probably a reflection of two factors.

If younger patients were treated for 10—20 years they would almost certainly achieve as much benefit. As shown by Psaty et al. For CHD, however, only low-dose diuretic-based therapy has been beneficial. Blood pressure at entry averaged mmHg systolic and 83 mmHg diastolic. During follow-up median 3. From Staessen et al.

Hypertension in older adults

Of these, six compared the newer antihypertensive agents, angiotensin-converting enzyme inhibitors ACEIs and calcium antagonists CAs against placebo Table RR, relative risk; CI, confidence interval. From Psaty et al.

Are hypertensive elderly patients treated differently?

Therefore, the somewhat greater benefit against stroke and heart failure found in the CA versus placebo trials than in the ACEI versus placebo trials is not surprising. None the less, the data are quite consistent with the other trials in the elderly, showing significant reductions in stroke and overall mortality with nifedipine 15 deaths in patients compared to placebo 26 deaths in patients. There are numerous potential reasons for this inadequacy, as detailed by Messerli et al. From Messerli et al. When should therapy be started? In the past, guidelines for the institution of therapy have been based solely on the level of blood pressure, giving rise to major irrationalities and inconsistencies.

As noted by Jackson et al. As Jackson et al. JNC-6 provides criteria for three risk groups, based on the level of blood pressure and the presence of major risk factors, such as target organ damage or clinical cardiovascular disease Table The recommendations are to start therapy in these three groups with either lifestyle modification alone or with drug therapy Table None the less, as we shall see later, lifestyle modifications certainly have an important role in the management of the elderly hypertensive.

The other expert committee guidelines recently published use overall cardiovascular risk as the primary criterion for 53 Table 11 Components of cardiovascular risk stratification in patients with hypertension Table 12 Risk stratification and treatment the decision to start antihypertensive therapy Ramsay et al.

Hypertension in the Elderly: Pocketbook by Norman Kaplan

None of the RCTs in the elderly included enough patients over the age of 80 to determine the value of antihypertensive therapy in such patients, the most rapidly growing part of our population. However, almost patients over age 80 were included in the various trials in the elderly, and they achieved similar protection against stroke and CHD as the less elderly, but not a reduction in mortality Gueyffier et al. Until trials now in progress provide definite evidence, the best course is to treat—ever so gently—very old patients with systolic blood pressure above mmHg or diastolic above 90 mmHg if they seem likely to have more than 1 year of life survival.

Those who are severely debilitated with endstage cancer or dementia are best left untreated. However, a year-old who can be protected from stroke or dementia and thereby allowed to maintain an enjoyable life should not be denied such benefit. Furthermore, there seems no reason to stop successful and well-tolerated therapy, regardless of the attained age. As will be noted later, almost all who are hypertensive before treatment will become hypertensive again if treatment is stopped. There are three possible relationships between the levels of blood pressure achieved by therapy and the risk 55 Figure 26 Three models of hypothetical relationships between levels of blood pressure and risk of cardiovascular disease.

Line A implies the lower the blood pressure, the less the risk, in keeping with the straight-line relationship between untreated levels of blood pressure and risk shown in Figure However, the results of the multiple RCTs described earlier have suggested that the consequences of therapy are more accurately portrayed as either line B, wherein little if any additional benefit is derived from increasingly greater reduction in blood pressure, or line C, wherein additional risks appear as the pressure is reduced below some initial level.

From the time in when the English practitioner I. Stewart reported a fivefold increase in heart attacks among patients whose diastolic blood pressure fourth Korotkoff phase was reduced below 90 mmHg, considerable arguments have either defended or denied the presence of a J-curve.


  • 100 Lessons on Happiness in 100 Words or Less (100 Lessons in 100 Words or Less).
  • Hypertension in the Elderly: Pocketbook!
  • Hypertension in the Elderly: Pocketbook by Norman Kaplan - Nemanja Maras Library.
  • The Droid Pocket Guide (Peachpit Pocket Guide).
  • Personality Assessment;
  • Praying to Change Your Life: 1.

The reason for so much discussion is the implication that therapy beyond a certain level could have serious adverse consequences. The HOT trial involved almost hypertensives aged 50—80 years mean They were randomly divided into three groups to receive drug therapy adequate to lower their diastolic blood pressure to either 90, 85 or 80 mmHg. From Hansson et al. Therefore, the existence of a J-curve could be neither denied nor documented because of the small degree of blood pressure differences.

No additional benefit was seen at lower pressures. The authors of the HOT trial paper provide arguments against the J-curve. However, a closer look at Figure 27 shows a rise—slight but definite—in cardiovascular event and mortality at diastolic pressures below 85 mmHg. Evidence for a J-curve for diastolic pressure The patients enrolled in the HOT trial had combined systolic and diastolic hypertension. As previously noted, the largest part of the elderly hypertensive population has isolated systolic hypertension ISH , starting with diastolic BP below 90 mmHg.

As also previously noted, the pressure fall in diastolic BP typically occurring over age 55 is, in itself, a risk factor. There is some evidence that further inadvertent reductions in diastolic BP by drug therapy of ISH may increase the risk of stroke.

Best books

However, subsequent analysis found an increase in stroke events in those whose diastolic BP was reduced more than 5 mmHg and to below 65 mmHg, compared to those with a lesser fall in diastolic levels Somes et al. Reference category is the second lowest category of diastolic blood pressure. Values are plotted on a logarithmic scale. Varying goals Based on these data, the goal for the elderly with ISH should be a systolic of mmHg, as long as the diastolic does not fall to below 65 mmHg Staessen et al. We will now turn to the therapies that will be needed to reach these goals, starting with lifestyle modifications and then drug therapy.

Not all of these have been studied in elderly patients, but their benefits almost certainly apply to them equally as much or even more. For instance, elderly people respond better to a lower sodium intake, i. Avoidance of tobacco Nicotine has an acute and often dramatic pressor effect that does not lessen with continued exposure.

Tolerance to Table 13 Lifestyle modifications for hypertension 61 Figure 29 Changes in systolic blood pressure over 15 minutes after smoking the first cigarette of the day in 10 normotensive smokers. From Groppelli et al. The pressor effect noted in addicted smokers from the cigarette smoked for 2 minutes is shown to persist for 15 minutes in Figure 29, but is gone by 30 minutes.

Therefore, the effect may not be recognized, as smoking is not allowed in clinics or offices where blood pressure is measured. Therefore, if possible, smokers should take their blood pressure while smoking. That reading should be the basis for deciding on therapy and the goal of therapy. Regardless of age or duration of smoking, every effort should be made to get the patient to stop smoking. Weight loss Weight gain is the most common direct environmental cause of hypertension.

Even relatively small amounts of weight gain increase the incidence of hypertension, as 62 shown in the report by Huang et al. Those who gained as little as 5 kg 11 lb from their weight at age 18 had twice as much hypertension as those whose weight did not change; with a 10kg 22 lb weight gain the incidence tripled. These data clearly indicate the major contribution of even modest weight gain to the risk for hypertension. Furthermore, those who lost weight had less hypertension, in keeping with a large body of data showing falls in blood pressure with weight loss Figure Difficult as it may be, particularly for the elderly, weight loss must be constantly Figure 30 Systolic and diastolic blood pressure before and after body weight reduction.

The short-term use of diet pills may be of some help, but caution is needed as most can raise blood pressure. Sodium restriction Despite a claim based on flawed data by Alderman et al. Modified from Cutler et al. The elderly are more sodium sensitive and therefore more likely to respond favorably to sodium reduction.


  • .
  • US Army, Technical Manual, TM 55-4920-378-14&P, TESTER, PITOT AND STATIC SYSTEM, (MFR. PART NO. TPS-;
  • Armed With Cameras;
  • .
  • Objectives:.
  • ;

However, two factors may make it more difficult for them to reduce sodium: The effort to reduce dietary sodium moderately is worthwhile and success can be achieved with counseling, the avoidance of processed foods with more than mg of sodium per portion as indicated on the label a major boon to sodium avoidance , and occasional checks of urinary sodium excretion. The TONE trial Perhaps the best documentation of the benefits and safety of modest sodium restriction, alone or combined with weight loss, in elderly hypertensives comes from the randomized controlled Trial of Nonpharmacologic Interventions in the Elderly TONE reported by Whelton et al.

The trial involved men and women aged 60—80 years with hypertension that was being well controlled on one or two medications. The patients agreed to discontinue their drugs and were then randomly allocated to four groups: From Whelton et al. Despite these modest changes, the number whose hypertension reappeared the primary end-point and who developed cardiovascular complications was far greater among the usual care group than among those who reduced either sodium intake or body weight.

Those who did both were protected even more. Subsequent analysis of the TONE data showed that, compared to those on usual care, those assigned to sodium reduction achieved a 4. The appropriate amount, i. Those who drink more than two portions on average per day must be strongly advised to cut back. Small amounts of daily alcohol consumption protect against coronary mortality, as shown in numerous surveys, including that of Thun et al. Occ, occasional; light, one to two daily; Mod, moderate, three to six daily; Heavy, more than six daily.

From Shaper et al. As expected, mortality from alcohol-related diseases increased with excessive consumption. The lower recommendation for women should circumvent any threat of stimulation of breast cancer by alcohol. Maintain adequate dietary potassium, calcium and magnesium Intake of these three minerals should be well maintained in the elderly, preferably by a diet containing adequate amounts of fresh fruits, vegetables and dairy products; if not, by mineral and vitamin supplements.

On the other hand, as reviewed by Sacks et al. More fresh fruits and vegetables reduce BP Sacks et al. These benefits may reflect many effects of such a diet: As shown by Hakim et al. The longer the walk, the lower the mortality. Such low-intensity activity will also lower blood pressure, probably contributing to the overall reduction in mortality.

Higher-intensity activity may be even better, both to aid in weight loss and to lower blood pressure. Pure isometric exercise weightlifting only raises blood pressure acutely; during aerobic or isotonic activity running, swimming systolic blood pressure increases and diastolic goes down. Afterwards both systolic and diastolic levels tend to remain lower.

Those elderly hypertensives who cannot walk, run or swim should be encouraged to use whatever exercise devices they can that are available at health clubs and retirement centers. Reduce dietary saturated fat and cholesterol There is very likely some benefit on the blood pressure when diet or statin drug therapy lowers serum LDL cholesterol. The effect is mediated by improvements in endothelial function, with increased synthesis of vasodilatory nitric oxide.

In most trials of lipid-lowering agents a slight but significant fall in blood pressure has been observed Goode et al. Other modalities Increased amounts of fiber, omega-3 fatty acids, garlic or oral antioxidants, as well as various relaxation techniques, have been claimed to lower blood pressure, but most of the trials are small, short and poorly 69 controlled Kaplan, None of these should have adverse effects, but do not expect them to lower blood pressure.

Two additional drugs are widely used among elderly hypertensives: Aspirin, 75 mg daily, was shown in the HOT trial to reduce coronary events but to increase nonfatal bleeding episodes. ERT, unlike oral contraceptives, does not raise blood pressure and can be given to hypertensive women without concern about their blood pressure.

After these lifestyle changes have been attempted, the blood pressure may remain above the goal, making drug therapy compulsory. Because the elderly may have sluggish baroreceptor and sympathetic nervous responsiveness as well as impaired cerebral autoregulation, therapy should be gentle and gradual, avoiding drugs that are likely to cause postural hypotension or to exacerbate other common problems often seen among the elderly Table Table 14 Factors that might contribute to increased risk of pharmacological treatment of hypertension in the elderly 71 These cautions should not however, interfere with the well-documented need to treat the overwhelming majority of elderly hypertensives.

The benefits they have been shown to receive from antihypertensive drug therapy, detailed earlier, are quantitatively greater than those provided to younger patients. No longer should age alone interfere with the provision of appropriate therapy. General guidelines The treatment algorithm shown in Figure 34 is well suited to the elderly hypertensive, with the caveat that most will Figure 34 Treatment algorithm based upon the use of a low dose of diuretic as the first choice and, if BP control is not achieved, the addition of a second drug determined by the presence of compelling indications.

As the majority of the elderly will have isolated systolic hypertension, attention will be directed to the compelling indications for diuretics as the preferred initial therapy, and the use of long-acting dihydropyridine DHP calcium antagonists as an appropriate second drug or, rarely, an alternative. Diuretics for initial therapy As shown earlier, a low-dose diuretic was the first drug used in most of the major randomized controlled trials in the elderly. A large amount of data from the Systolic Hypertension in the Elderly SHEP trial has confirmed the efficacy and safety of the step 1 drug chlorthalidone, started at As reported by Savage et al.

Biochemical changes were relatively minimal over the 3 years of active therapy Table These data, along with those from the other RCTs described earlier, strongly support the preference given to low-dose diuretics for the elderly. Emphasis should be given to the low doses, equivalent to Long-acting dihydropyridine calcium antagonists As described earlier, four RCTs have been completed comparing one of these agents against placebo in elderly patients with isolated systolic hypertension ISH.

All three showed excellent protection from both stroke and coronary disease with either longacting nitrendipine or nifedipine. The cardioprotection provided by these long-acting DHP calcium antagonists should allay any concerns about the danger noted with very large doses of short-acting nifedipine in the highly vulnerable post myocardial infarction period Brown et al.

Long-acting antagonists do not lower blood pressure abruptly, thereby avoiding the activation of sympathetic activity that is seen with short-acting agents Grossman and Messerli, Another concern about short-acting calcium antagonists— their promotion of cancer—as reported in 74 retrospectiveuncontrolled observations has also been clearly documented not to apply to the long-acting agents.

In the Syst-Eur trial Staessen et al. Numerous large surveys have documented the absence of any relationship between calcium antagonists and cancer Kizer and Kimmel, These include amlodipine, felodipine, nicardipine, nifedipine XL and nisoldipine. One conclusion seems obvious: Certainly, calcium antagonist-based therapy protected better against stroke and less well against CHD and CHF, but the two forms of therapy were identical in their effects on overall morbidity and mortality rates.

Furthermore, a good deal of admixture occurred in these trials. In one Estacio et al. Table 16 shows data from the two trials that directly compared an ACEI with a calcium antagonist Estacio et al. The results of the trials completed since are by no means definitive. As He and Whelton noted: Fortunately, many trials are in progress, so that more definitive data to guide our choices of therapy will soon be available.

Of course, the playing field keeps growing. By the time we know whether ARBs are as good as ACEIs, vasopeptidase inhibitors will probably be available, so the process of finding out what is best will probably never end. In one sense the process is irrelevant. As the need to achieve lower goals of therapy has become obvious, the need to use more than one drug in the majority of hypertensive patients has also become obvious.

This is nowhere better seen than among elderly diabetic hypertensive patients, who will be considered in the next section. Therefore, the best combination of agents, almost always to include a low dose of diuretic, will be a more pertinent object of trials in the future. Drugs for specific indications A variety of comorbid conditions that are often seen in elderly hypertensives may be favorably influenced by oneclass of drug or another, whereas others may be adversely affected by certain drugs.

However, the wisdom of using an a-blocker to relieve the symptoms of prostatism while also lowering the blood pressure is obvious. As noted by Lieber , ablockade is now the accepted initial therapy for most patients with urinary obstructive symptoms, so that only one drug will often manage the two conditions, hypertension and BPH, which occur together in as many as 25 of elderly men.

Concerns about a-blockers arising from the termination of that arm of the ALLHAT trial because of an apparent increased incidence of heart failure compared to the diuretic arm ALLHAT, should not deny their use along with a low dose of diuretic when indicated. If the blood pressure is still too high, a calcium antagonist may be required. Patients with renal insufficiency, defined as a serum creatinine above 1. ACEIs are always indicated.

If diabetic nephropathy is the cause of renal damage, an ARB may be chosen instead. Most will require a third drug, and a calcium antagonist is often the best choice to control hypertension. Special guidelines for the elderly These recommendations should be helpful in controlling hypertension in the elderly, in addition to those described later that are aimed at improving overall compliance with therapy Kaplan, Always check for postural and postprandial hypotension before starting antihypertensive drug therapy to avoid even more precipitous falls in blood pressure.

If present, utilize the various maneuvers described earlier to overcome the postural and postprandial falls in blood pressure. Start with a low dose of a thiazide diuretic, preferably in combination with a potassiumsparing agent; if the serum creatinine is above 1. If the diuretic is inadequate or poorly tolerated, add or substitute a long-acting DHP calcium antagonist, again starting with a dose one-half the usual starting dose.

Titrate slowly, every 4—8 weeks, until control is attained. Use agents in addition to diuretics or DHP calcium antagonists that provide favorable influences on comorbid conditions, as noted in Figure If a b-blocker is indicated, as with angina or post myocardial infarction, or an alpha-blocker for prostatism, always add a low dose of thiazide diuretic. Always use once-a-day dosing with long-acting agents that provide full hour efficacy. Agents such as amlodipine and trandolapril, with inherently longer durations of action, are particularly attractive to cover the days when doses are skipped—a common occurrence.

Some, such as grapefruit juice, potentiate antihypertensive effects, but the most common interaction is with non-steroidal anti-inflammatory agents NSAIDs , which will antagonize the effects of all agents save calcium antagonists Harris and Brater, Johnson recommends the use of physical therapy and other analgesics such as acetaminophen, which do not interfere with antihypertensive drug efficacy. Erectile dysfunction Erectile dysfunction is common in elderly men, usually a consequence of atherosclerotic impairment of penile blood flow. Hypertension may add to the problem, which may be further aggravated by antihypertensive therapy.

As reported by Grimm et al. Only 15 mg of chlorthalidone was used, so the problem can obviously be exacerbated by low doses of diuretics. Now the best course, if the antihypertensive therapy is otherwise effective and well tolerated, may be to simply give sildenafil, which should have no interaction with any antihypertensive drug. Caution is obviously needed to avoid the use of sildenafil with nitrates that may induce profound hypotension. Even if all the guidelines are followed, compliance with therapy may be poor.

Advice to improve compliance is provided next. According to a survey of over hypertensives in England reported by Jones et al. On the other hand, Monane et al. Compliance worsened when multiple drugs were prescribed and improved with more physician visits. Unfortunately, hypertension and its treatment fulfill many of the criteria that are known to reduce adherence to any therapy Table As hypertension is an asymptomatic, Table 17 Factors that reduce adherence to therapy 82 Table 18 General guidelines to improve patient adherence to antihypertensive therapy 83 chronic incurable condition whose treatment requires daily therapy that may cause side effects and which provides no obvious benefit, it is easy to see why so few patients adhere closely to their therapy.

Table 18 provides general guidelines to improve patient compliance with therapy. Unfortunately, few of these have been documented to be successful. In their review of all published randomized trials of interventions to improve compliance Haynes et al. Five of these involved hypertensives. Improved adherence to antihypertensive therapy was noted with these interventions.

The elderly often have additional impediments to adherence to therapy, ranging from difficulty in opening childproof containers to an inability to pay for expensive drugs, to difficulty in reaching their healthcare providers. Hopefully, the guidelines provided in Table 18 and elsewhere in this book will help physicians and their patients to achieve the true goal of antihypertensive therapy: Dietary sodium intake and mortality: Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone. Effects of reduced sodium intake on hypertension control in older individuals.

Arch Intern Med ; Fetal origins of coronary heart disease.

Hypertension in the Elderly: Pocketbook - PDF Free Download

Br Med J ; Factors common to all techniques. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: Congenital oligonephropathy and the etiology of adult hypertension and progressive renal injury. Am J Kidney Dis ; Technique of blood pressure measurement. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: The prognosis of hypertension according to age at onset.

Since the chi-square test determined unadjusted general associations between geriatric age of patient and region, pairwise comparisons were also performed to determine the specific regional differences. Mantel-Haenszel chi-square tests were performed to determine the associations between geriatric age and the demographic variables of gender, race, insurance type, urban status, and region as stratified by survey year.

The results of the stratified analysis indicated similar associations between geriatric age and the demographic variables. Within each year strata, the association between geriatric age and the demographic variables were the same. Bivariate analyses were first performed to determine unadjusted associations between antihypertensive class and geriatric age. Each analysis controlled for patient gender, race white or non-white , insurance type self-pay, all other , urban status metropolitan area, non-metropolitan area , geographic region Northeast, Midwest, South, or West , and NAMCS year — Prescribing time patterns of each antihypertensive medication class were also explored.

First, unadjusted chi-squared analyses determined general associations between year — and each of the antihypertensive medication classes. This analysis determined if the time trend associations remained when the essential hypertensive population was restricted by age less than 65 years, 65 years of age or older. These analyses were performed only for hypertensive classes with sample sizes large enough to produce reliable estimates according to National Center for Health Statistics NCHS standards number of sampled patient visits is at least 30 and the relative standard error is less than 0.

Multivariate logistic regression analysis determined adjusted association between antihypertensive class and prescribing year while controlling for demographic variables discussed above. Statistical associations were determined at the alpha level of 0. All estimates reported are reliable by NCHS standards. Per the NAMCS database, an estimated essential hypertension patient visits occurred during — Of these hypertensive patients, Hypertensive patients 65 years and older were more likely female All other p-values indicate pairwise differences between geriatric age category for each region category.

Hypertensive patients who were 65 years of age or older were more likely to be prescribed or already using diuretics adjusted odds ratio [adj OR] — 65 yrs or older: The proportion of essential hypertensive patients prescribed BBs appear to decrease between and ; whereas the proportion of essential hypertensive patients prescribed ARBs appear to increase. Our results demonstrate that hypertensive patients aged 65 and over were treated differently than their younger counterparts in the US from — However, the prescription of diuretics, CCBs, A1Bs, and A2Ags was significantly more frequent in the older population than in younger hypertensives.

Our theories regarding this discrepant prescribing are detailed below. Their preferential use in the group aged 65 and older may reflect adherence to evidence-based guidelines such as JNC 6. This study shows that CCBs were preferentially prescribed more often than BBs to all hypertensive patients, regardless of age. At best, physicians were following the evidence in some ways eg, by prescribing diuretics frequently while eschewing them in others.

Possibly, physician perceptions of frequent BB side effects led to this behavior Ubel et al Publicity for CCBs by drug representatives may have led to more frequent prescription for the general population, but this does not explain their preferential use in the geriatric population. Caution is urged in the prescription of A1Bs to the elderly due to potential orthostatic hypotension, and yet these agents were preferentially used in the elderly population.

One can surmise this is likely due to the frequent co-morbidity of benign prostatic hyperplasia BPH in elderly men. However, it is interesting to note that these medications were specifically noted in a visit coded for hypertension, so some practitioners may have considered these to be good medications for high blood pressure in their elderly male patients regardless of the degree of BPH which was present. A2Ags were also prescribed preferentially to the geriatric population despite concerns that cognitive dysfunction, notably sedation, may occur when used in this group JNC We hypothesize that these medications were prescribed years ago when there were few alternatives and if they were well-tolerated, they were continued by practitioners.

Simply put, the longer that someone has been hypertensive, the more likely they are taking an older medication. Clearly, the geriatric population would be more likely to have been hypertensive for a longer period of time than younger adults. One other theory is that the convenience of once-weekly topical dosing options with clonidine patches leads to greater use in older adults who may suffer from memory impairment or difficulties in swallowing pills. There are several caveats to consider in reviewing our results.

Patients who are hypertensive may not have been included in the database search because the reason for that visit was for a separate issue eg, ankle sprain. Also, we do not necessarily have a full medication list on our hypertensive patients. The discretion of the physician seeing the patient dictated what was listed. Summing the prevalence of the medications prescribed shows patients averaged just over one medication in both elderly and younger adult categories.

If a newer medication was added to the prior regimen eg, CCB added to an existing regimen of BB and diuretic , we could overestimate the relative prevalence of the newer medications compared with the older agents. However, the fact that diuretics were the leading medication listed for the elderly population suggests this is not the case. For example, if we knew that many of the elderly patients on ACEIs had diabetic nephropathy, there would be excellent evidence for using that medication preferentially in that group. Likewise, if we knew all of the elderly patients on A1Bs had symptomatic BPH, then we would have a reasonable explanation for its prescription.

Data are at least six years old in a rapidly changing field. This suggests additional efforts to promote adherence to JNC 7 may be helpful in increasing the practice of evidence-based medicine. Sampling error is possible with the use of weighted data. This is an inherent limitation of using the NAMCS database as it must be weighted for proper interpretation. It is set up to illustrate nationwide practices and individual patient encounters must be weighted in order to achieve this. We evaluated only the relatively healthy elderly population which is seen in the ambulatory setting.

However, we believe this is appropriate for comparing the prescription of antihypertensives in older and younger adult populations, and for considering adherence with JNC 6. The hypertensive population aged 65 and older was treated with different medications than their younger counterparts in the late s. The increased usage of diuretics and CCBs was evidence-based.

BBs were under-prescribed in the hypertensive population at large, likely due to exaggerated physician beliefs that they are poorly tolerated Ubel et al Physicians did not adhere to the recommendations of the well-publicized hypertension practice guidelines, JNC 5 and 6. This cross-section of American physician antihypertensive prescribing practices demonstrates the need for continued evidence-based provider education.