REVIEW IN DEPTH

Quality of life in the elderly hypertensive

Maria I. Nunes
The approach to the treatment of hypertension in the elderly
hypertensive should take into account the effects of the different
antihypertensive drugs on the quality of life, especially in the
elderly where a small reduction in health status could have an
impact on their independence. J Cardiovasc Risk 2001,
8:265269 2001 Lippincott Williams & Wilkins.

Journal of Cardiovascular Risk 2001, 8:265269

Keywords: elderly, hypertension, quality of life
Imperial College School of Medicine, Hammersmith Hospital, London,
UK.
Correspondence and requests for reprints to Maria I. Nunes, Imperial
College School of Medicine, Hammersmith Hospital, Du Cane Road,
London, W12 0NN, UK.
Tel: +44 (0) 208 383 4287; fax: + 44 (0) 208383 3378;
e-mail: m.nunes@ic.ac.uk

Introduction
In most industrialized countries, the mean life expectancy is increasing hence the increase in the elderly
population. The very elderly, people aged 80 years and
over, is the fastest growing segment of the population
w1x. Cardiovascular disease is the leading cause of death
among elderly people in developed countries w2x and
experimental data from clinical trials has clearly demonstrated the benets of treating hypertension in patients
aged 6079 in reducing cardiovascular morbidity and
mortality.
Demographic changes have led to an increase in the
importance of chronic disease as part of the health
experience of the population, therefore the emphasis is
no longer on cure but on living with an on-going disorder w3x. Therefore the assessment of quality of life is
becoming increasingly more recognized as an essential
outcome measure for hypertensive patients. In the very
elderly 80 q ., due to the limited amount of experimental data, the benet of treating this age group is not
clearly demonstrated w4x. However, trials targeting this
age group are under way and should provide evidence
as to whether it is worth treating the very elderly
hypertensive.

Assessment and measurement of quality of

life
The term quality of life QOL. is increasingly being
used in different elds and with different meanings w5x.
Although there is no consensus on an exact denition of
quality of life, it has been suggested that quality of life
is the measure of the gap between patient expectations
and achievements w6x. However, James and Potter w7x
pointed out that it is impossible to provide an exclusive
denition because the quality of life as perceived by an
individual is complex, subjective and inuenced by a
multitude of factors. Because the quality of life concept
is difcult to dene, it is also difcult to measure it in a
scientic way w7x. However, in terms of health-related
QOL, the consensus achieved is that measures in hypertensive patients should include symptomatic and
psychological well-being, activity work, leisure, sleep,
sexual activity and social participation., cognitive function, and life satisfaction w8x.
A large number of instruments, mainly questionnaire1350-6277 2001 Lippincott Williams & Downloaded
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266 Journal of Cardiovascular Risk 2001, Vol 8 No 5

based have been developed to assess and to quantify

the different domains, which comprise quality of life
w7x. These instruments have been designed either to be
self-administered or completed by an observerrinterviewer. The method used to assess quality of life will
depend on a variety of factors, such as the costs, complexity, difculty level of the interview and the patients
state of health and literacy w5x. Generally speaking,
self-administered questionnaires are preferable as
patient input is essential w9x, provided that it is administered under standard conditions, i.e. patients should
complete it in a quiet area at the medical centre, before
seeing the doctor and having their blood pressure measured. It is also considered the safest neutral method,
although those who are not literate would be excluded
w5x. Self-administered questionnaires are usually used in
large multi-centre trials, where it may not be practicable
to train, standardize, and deploy interviewers w5x. In the
elderly, problems with eyesight, understanding, and not
being familiar with the format could hinder the accuracy of self-administered questionnaires and therefore
interview-administered questionnaires may be preferable w10x. However, this method can introduce interviewer bias and expectations, as there is always the
possibility that the patients perception do not coincide
with that of the interviewer w11x.
This point was highlighted in one of the rst studies of
the effects of antihypertensives on quality of life. In
this study the quality of life of 75 subjects on antihypertensive medication was assessed via a questionnaire.
The ndings showed that 100% of the physicians reported improvement on quality of life, since blood
pressure had come under control, and the subjects did
not complain. However, only 48% of subjects reported
improvement and 98% of the subjects family members
reported that the subjects quality of life had deteriorated on treatment w12x. However, this study was awed
since the three groups of respondents were asked different questions.

Effects of antihypertensive treatment on

quality of life
In the last 10 years, experimental data from clinical
trials have considerably added to the knowledge of the
benets of treating hypertension in elderly subjects
w13x. It is well documented in clinical literature that the
treatment of both systolic and combined systolic and
diastolic hypertension in the elderly reduces cardiovascular morbidity and mortality. However, in certain situations a number of persons must be treated in order to
obtain a moderate reduction in events w14x, thus many

subjects do not benet. Moreover, it has been suggested that the treatment of hypertension in elderly
hypertensives might have an adverse effect on cognition, mood, or leisure activities w15x. Therefore, the
effect of treatment on measures of quality of life requires consideration, since the benets should clearly
outweigh the risks, especially in the elderly where a
small reduction in health could limit their activities of
daily living.

Non-pharmacological intervention
It has been recommended that when possible, nonpharmacological means such as weight loss, limitation of
alcohol intake, reducing sodium intake and increasing
physical activity should be the rst method employed
to reduce hypertension in the elderly w4,7,16x. However,
the general perception is that elderly patients are more
resistant in following lifestyle therapy w16x, although the
Trial Of Non-pharmacologic interventions in the Elderly TONE. reported that change in lifestyle can be
achieved in this age group w17x.

Effects on QOL of different antihypertensive

drugs
The TONE trial also assessed the quality of life and its
correlates among elderly patients with medication-controlled hypertension. The ndings revealed that the
predominant correlate of health-related QOL at baseline was the presence of physical symptoms, and not
age or medication class. A total of 975 men and women
aged 60 to 81 years and free of major diseases and
disability, with a screening blood pressure of
F 145r85 mmHg, were studied while being treated
medically for hypertension with antihypertensive medication. The medication groups were diuretics, betablockers, calcium-channel blockers, and ACE-inhibitors.
It was reported that none of these medications appeared more benecial or harmful in terms of QOL.
One exception was an association of higher depressive
symptomatology among a sub-group of men taking blockers w17x. In contrast, the Treatment Of Mild Hypertension Study TOMHS. w18x found improvements
in quality of life with placebo, amlodipine, doxazonin
and enalapril but the largest improvement was with
-blocker acebutolol and the diuretic, chlorthalidone.
These patients were aged 4569 years.
The Swedish Trial in Old Patients with Hypertension
STOP-2. w19x compared the use of conventional therapy hydrochlorothiazideramiloride combination andror
one of three -blockers. with newer therapy a

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Quality of life in hypertension in the elderly hypertensive Nunes

calcium-channel blocker or an ACE inhibitor. on the

treatment of elderly hypertensives aged 7084. The
results have shown that both the conventional and
new drugs were similar in the prevention of cardiovascular mortality or major events. One important aspect of
the ndings was the differences in rates of adverse
reactions. These rates were particularly high for ankle
oedema 25.5%. for patients taking calcium antagonists,
and dry cough 30%. for patients taking ACE inhibitors.
The rate for dizziness was also high 2528%. and
similar for each regimen. It seems that these and other
adverse reactions were more common than many clinicians would expect and could be partly explained by
the fact that all the events, which occurred in the trial at
any time, were recorded w20x and the fact that there was
no placebo incidence that could be taken into account.
Based on the ndings above, it seems that the
decision-making process of which drug to choose for the
treatment of elderly hypertensives, should be aided by
information on the effects of these medications on
quality of life. Needless to say that contra-indications
and side effects should also be taken into account.

Diuretics
The existing clinical data on low-dose diuretics has
shown that they are efcacious, inexpensive, and well
tolerated, especially in the elderly w21x. The Systolic
Hypertension in the Very Elderly Program SHEP. trial
was a multi-centre, randomized, double-blind, placebocontrolled trial of patients 60 years or older. The trial
was designed to compare the effect of diuretic and
-blocker-based antihypertensive treatment on isolated
systolic hypertension ISH.. The 4736 participants were
randomized to either active hypertensive drug or matching placebo. The trial was also designed to assess the
impact of the antihypertensive treatment on measures
of cognitive, emotional, and physical function and
leisure activities. The SHEP behavioural evaluation was
administered after randomization and before treatment
started. Cognitive impairment, depression, and mood
disorders were evaluated twice a year and measures of
activity of daily living and social network were assessed
once a year. In addition, once a year subjects in six of
the 16 clinical centres involved in the trial, received
more detailed tests of cognitive function, including
psychomotor speed, attention span, visual scanning,
mental calculation, expressive language function, verbal
memory, and hypothesis testing. The results demonstrated that medical treatment of ISH decreases the
incidence of cardiovascular events without causing deterioration on measures of quality of life. The results also
reported, for some measures, a small positive effect on

267

cognitive, physical and leisure functions in the treatment group w14x.

In another study reporting the effects of antihypertensive drugs on QOL in younger subjects, male patients
reported an increase in sexual dysfunction with
chlorthalidone compared to placebo w22x.

Beta-blockers
In a review of several randomized quality of life trials,
atenolol was compared to ACE inhibitors, diuretics and
verapamil, and the ndings revealed that there was no
difference in the change in QOL after treatment w8x.
In a recent study comparing bisoprolol with nifedipine
retard, although no statistically signicant difference
was found between the two groups at 8 weeks, the
analysis of the results of the last assessment usually 24
weeks. showed improvements in tensionranxiety,
angerrhostility, vigourractivity, and confusionrbewilderment in patients receiving bisoprolol w23x.
The SHEP trial used a -blocker as a second line
agent. Atenolol, when added to chlorthalidone, proved
to assist in the control of ISH. Also as mentioned
previously, treatment in the trial did not have a negative impact on measures of QOL.

Calcium channel blockers

It has been suggested that calcium blockers have a
favourable effect on QOL when compared with other
drugs w6x, but double-blind trials have reported high
rates of side effects and withdrawals with the short
acting drug, nifedipine w24x. The Systolic Hypertension
in Europe Trial Syst-Eur. trial was a randomized,
multi-centre, double-blind, placebo-controlled trial in
patients 60 years and older w25x. Active treatment consisted of a calcium-channel blocker nitrenidipine
1040 mg daily., combined with an ACE-inhibitor enalapril 520 mg daily. and diuretic hydrochlothiazide
12.525 mg daily., if needed. The trial recruited 4695
subjects and included the assessment of QOL and
cognitive function. The results revealed a lower incidence of dementia in the treatment group compared
with placebo and treatment did not impair cognitive
function w26x. The results from the analysis of the
baseline QOL have been published and they demonstrated the heterogeneity of patients in terms of QOL.
Further analysis will determine if the baseline ndings
will have an inuence on QOL during randomized
treatment w27x.

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268 Journal of Cardiovascular Risk 2001, Vol 8 No 5

Angiotensin converting enzyme (ACE)

inhibitors

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It has been shown that ACE inhibitors are efcacious in

treating hypertension in elderly patients despite the
reduction in renin activity with increasing age w7x. These
drugs compare well with other antihypertensive groups
in QOL studies because they have been shown not to
cause fatigue, cognitive or memory impairment, depression, weakness or sexual dysfunction w7x. However, it is
well recognized that they produce a dry cough in up to
a fth of patients.

Bulpitt CJ. Controlling hypertension in the elderly. Q J Med 2000;

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Bulpitt CJ, Fletcher AE. The measurement of quality of life in

hypertensive patients: a practical approach. Br J Clin Pharmacol 1990;
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Calman KC. Quality of life in cancer patients-an hypothesis. J Med

Ethics 1984; 10:124 127.

James MA, Potter JF. The effect of antihypertensive treatment on the

quality of later years. Drug Ther 1993; 1:26 39.

Bulpitt CJ, Fletcher AE. Quality of life evaluation of antihypertensive

drugs. Pharmaco Economics 1992; 2:95 102.

Slevin ML, Plant H, Lynch D, Drinkwater J, Gregory WM. Who should

measure quality of life, the doctor or the patient? Br J Cancer 1988;
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QOL in the very old hypertensive

10 Bulpitt CJ, Fletcher AE. Antihypertensive drugs and quality of life in the
elderly. J Card Pharm 1989; Suppl 10:S21 S26.

At present there is insufcient evidence from randomized trials for or against treatment for those over 80.
Data on the effects of antihypertensive treatment on
QOL for this age group are also scarce. The Hypertension in the Very Elderly Trial HYVET. is currently
under way and will address the issue of benetrrisk
comparison from active treatment. The HYVET trial is
a randomized, double-blind, multi-centre, placebo-controlled study w4x. The trial has included the assessment
of QOL and cognitive function as a side project.
It has been argued that available data on the treatment
of hypertension in the very elderly suggests that although treatment may not prolong life, or even shorten
it, by preventing non-fatal strokes it may have a benecial impact on quality of life w1,28x. However, each
scenario requires careful consideration w1x. The Study
on COgnition and Prognosis in the Elderly SCOPE. is
also currently under way and will be assessing the
impact of antihypertensive treatment on major cardiovascular events and on cognition and quality of life in
patients aged between 70 and 89 years w29x.

Outcome measures of quality of life are an important

part of the assessment of antihypertensive treatment in
elderly subjects, especially as many of the drugs reduce
cardiovascular events and mortality to a similar extent.
Therefore in common with therapeutic contra-indications and side effects, the effect of different drugs on
quality of life is also an important issue to be considered when developing an approach to antihypertensive therapy in the elderly patient.

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