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    Opinion: Treat hypertension in the elderly

    Set a goal, start low, go slow, and try to get to goal!


    12


    Fredrick T. Sherman
    Hypertension is ubiquitous in the elderly, causing cardiovascular, cerebrovascular, and peripheral vascular complications that impair function, decrease quality of life, and increase mortality. Despite reams of data documenting the benefits of treatment of hypertension well into late life, many of our elderly patients never achieve their goal blood pressures because we fail to treat them adequately, they fail to adhere to our treatment recommendations, they develop side effects, or they have resistant hypertension.1 Knowing what we know in 2009, it is never too late to treat hypertension. Just set a goal, start low, go slow, and try to get to goal while monitoring for orthostatic hypotension and other adverse drug effects.

    More than 35 years ago, when I first entered the field of geriatrics, we Americans often looked east, across the pond, to the British for advice on how to treat our elderly patients. The Brits told us that a normal systolic blood pressure was considered to be your age plus 100.2 So for the typical 80 year old, a systolic blood pressure of 180 mm Hg (80 plus 100) was needed, so they said, to maintain perfusion in partially blocked arteries. Adding credibility to the "age plus 100" rule, epidemiologic studies consistently suggested that lowering the blood pressure in people 80 years old and older was associated with an increased death rate.3 Treatment also was complicated by the limited number of antihypertensive medications available, many with side effect profiles resulting in poor adherence and serious adverse outcomes including falls, confusion, and depression. Because of the lack of both epidemiologic and treatment data, we clinicians were not convinced that hypertension in the elderly was a problem deserving aggressive treatment.

    Then came the Framingham Study, which showed that the prevalence of hypertension tripled from 25% in those younger than 60 years old to 75% in people 80 years old and older and significantly increased the risks of stroke, myocardial infarction, congestive heart failure, and death. Isolated systolic hypertension (ISH) accounted for 60% to 75% of all cases of hypertension in the elderly.4 Framingham also taught us that systolic blood pressure was a much stronger predictor of adverse outcomes except in middle-aged and younger adults, where the diastolic pressure was a better predictor. Subsequently, tens of thousands of elderly patients with hypertension, both systolic/diastolic and ISH have been studied in randomized, controlled trials all over the world, showing the benefits of treatment.5 The recently published Hypertension in the Very Elderly Trial (HYVET) showed that in patients (mean age, 84 years) with sitting blood pressures of 173/90 mm Hg, the majority without cardiovascular disease, a decrease of 15/6 mm Hg resulted in significant reductions in all-cause mortality (21%), death rate from stroke (39%), and heart failure (64%). There were nonsignificant reductions in the rate of fatal and nonfatal stroke (30%) and in the rate of death from cardiovascular causes (23%). The HYVET authors recommended treating elderly patients with sustained systolic blood pressure of 160 mm Hg or higher to a target blood pressure of less than 150/80 mm Hg.6

    The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends treating blood pressure in the elderly when above 140/90 mmHg and above 130/80 mmHg for patients with diabetes, chronic kidney disease, or cardiovascular disease because of substantial cardiovascular risk reduction if treated.7 Some experts disagree with the systolic pressure goal of 140 mm Hg in those with ISH, suggesting that the HYVET study goal of less than 150 mm Hg is more appropriate and likely to be attained in those more than 80 years of age.8,9

    Despite these huge gains in the benefits of treating hypertension in the elderly, we do poorly in reaching these goals. As pointed out by Gibson, Fritz, and Kachur in this issue of Geriatrics in their comprehensive clinical review on hypertension in the elderly, simplifying the dosing regimen is the most effective single intervention to improve patient adherence to their hypertension regime. Less effective, more labor-intensive strategies include home monitoring, small-group training, and reminder calls.10

    The take-home message for primary care physicians is that systolic blood pressures in the elderly above 160 mm Hg should be lowered to a goal of less than 140 mm Hg and less than 130 mm Hg in those with diabetes, chronic kidney disease, and cardiovascular disease. In those more than 80 years old with ISH, a goal of 150 mm Hg may be more appropriate. Whichever recommendations you choose to follow, just choose a goal systolic blood pressure, 130 mm Hg, 140 mm Hg, or 150 mm Hg, and try to find the right combination of antihypertensives to get there without adverse effects. It's your job to help your elderly patient adhere to the medications you prescribe. Simplifying the regimen will benefit you both.

    Dr Sherman is clinical professor of geriatrics and medicine, The Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, and Chief Medical Officer for Community and Managed Care Services in ArchCare, New York, NY. He won the 2008 Jesse H. Neal award for opinion columns from American Business Media.

    12

    12


    Fredrick T. Sherman
    Hypertension is ubiquitous in the elderly, causing cardiovascular, cerebrovascular, and peripheral vascular complications that impair function, decrease quality of life, and increase mortality. Despite reams of data documenting the benefits of treatment of hypertension well into late life, many of our elderly patients never achieve their goal blood pressures because we fail to treat them adequately, they fail to adhere to our treatment recommendations, they develop side effects, or they have resistant hypertension.1 Knowing what we know in 2009, it is never too late to treat hypertension. Just set a goal, start low, go slow, and try to get to goal while monitoring for orthostatic hypotension and other adverse drug effects.

    More than 35 years ago, when I first entered the field of geriatrics, we Americans often looked east, across the pond, to the British for advice on how to treat our elderly patients. The Brits told us that a normal systolic blood pressure was considered to be your age plus 100.2 So for the typical 80 year old, a systolic blood pressure of 180 mm Hg (80 plus 100) was needed, so they said, to maintain perfusion in partially blocked arteries. Adding credibility to the "age plus 100" rule, epidemiologic studies consistently suggested that lowering the blood pressure in people 80 years old and older was associated with an increased death rate.3 Treatment also was complicated by the limited number of antihypertensive medications available, many with side effect profiles resulting in poor adherence and serious adverse outcomes including falls, confusion, and depression. Because of the lack of both epidemiologic and treatment data, we clinicians were not convinced that hypertension in the elderly was a problem deserving aggressive treatment.

    Then came the Framingham Study, which showed that the prevalence of hypertension tripled from 25% in those younger than 60 years old to 75% in people 80 years old and older and significantly increased the risks of stroke, myocardial infarction, congestive heart failure, and death. Isolated systolic hypertension (ISH) accounted for 60% to 75% of all cases of hypertension in the elderly.4 Framingham also taught us that systolic blood pressure was a much stronger predictor of adverse outcomes except in middle-aged and younger adults, where the diastolic pressure was a better predictor. Subsequently, tens of thousands of elderly patients with hypertension, both systolic/diastolic and ISH have been studied in randomized, controlled trials all over the world, showing the benefits of treatment.5 The recently published Hypertension in the Very Elderly Trial (HYVET) showed that in patients (mean age, 84 years) with sitting blood pressures of 173/90 mm Hg, the majority without cardiovascular disease, a decrease of 15/6 mm Hg resulted in significant reductions in all-cause mortality (21%), death rate from stroke (39%), and heart failure (64%). There were nonsignificant reductions in the rate of fatal and nonfatal stroke (30%) and in the rate of death from cardiovascular causes (23%). The HYVET authors recommended treating elderly patients with sustained systolic blood pressure of 160 mm Hg or higher to a target blood pressure of less than 150/80 mm Hg.6

    The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends treating blood pressure in the elderly when above 140/90 mmHg and above 130/80 mmHg for patients with diabetes, chronic kidney disease, or cardiovascular disease because of substantial cardiovascular risk reduction if treated.7 Some experts disagree with the systolic pressure goal of 140 mm Hg in those with ISH, suggesting that the HYVET study goal of less than 150 mm Hg is more appropriate and likely to be attained in those more than 80 years of age.8,9

    Despite these huge gains in the benefits of treating hypertension in the elderly, we do poorly in reaching these goals. As pointed out by Gibson, Fritz, and Kachur in this issue of Geriatrics in their comprehensive clinical review on hypertension in the elderly, simplifying the dosing regimen is the most effective single intervention to improve patient adherence to their hypertension regime. Less effective, more labor-intensive strategies include home monitoring, small-group training, and reminder calls.10

    The take-home message for primary care physicians is that systolic blood pressures in the elderly above 160 mm Hg should be lowered to a goal of less than 140 mm Hg and less than 130 mm Hg in those with diabetes, chronic kidney disease, and cardiovascular disease. In those more than 80 years old with ISH, a goal of 150 mm Hg may be more appropriate. Whichever recommendations you choose to follow, just choose a goal systolic blood pressure, 130 mm Hg, 140 mm Hg, or 150 mm Hg, and try to find the right combination of antihypertensives to get there without adverse effects. It's your job to help your elderly patient adhere to the medications you prescribe. Simplifying the regimen will benefit you both.

    Dr Sherman is clinical professor of geriatrics and medicine, The Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, and Chief Medical Officer for Community and Managed Care Services in ArchCare, New York, NY. He won the 2008 Jesse H. Neal award for opinion columns from American Business Media.

    12