HYPERTENSION IN ELDERLY

INTRODUCTION
The age-associated increase in blood pressure combined with the worldwide demographic increase in the aging population translates to an enormous emerging public health problem.

In addition to the well-ascribed hypertension risk factors of cardiovascular disease and stroke, it is also a significant risk for chronic kidney disease, atrial fibrillation, congestive heart failure (CHF, including diastolic dysfunction), and cognitive impairment

 Lowering blood pressure by 10 mmHg systolic and 5mmHg diastolic at age 65 years is associated with a reduction of up to 25% in myocardial infarction, 40% in stroke, 50% in CHF, and 10% to 20% overall decrease in mortality

EPIDEMIOLOGY
The National Health and Nutrition epidemiological surveys have documented that hypertension is a very prevalent condition among older Americans Based on this studys definition of hypertensionthe average of three readings 140 mmHg systolic and/or 90 mmHg diastolic or those receiving an antihypertensive medication the overall prevalence for hypertension among those aged 65 years or older ranges between 50% and 75%. For women aged 75 years and older, the prevalence exceeds 75%.

Lifetime Risk of Developing Hypertension in Middle Aged

(Vasan et al, JAMA 2002; 287: 1010)

Risk for Hypertension in a 55 year old Time, yr 10 15 20 25 Women 52% 72% 83% 91% Men 56% 78% 88% 93%

Guidelines
The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults:

Category
Normal Pre-hypertension

Systolic

Diastolic

Stage 1 hypertension
Stage 2 hypertension

<120 120-139 140-159 >160

and or or or

<80 85-89 90-99 >100

CHARACTERISTICS OF HYPERTENSION IN THE ELDERLY

Increased

Systolic blood pressure and pulse pressure

Left ventricular mass and wall thickness Arterial stiffness Calculated total peripheral resistance Decreased Cardiac output and heart rate Renal blood flow, plasma renin activity, and angiotensin II levels Arterial compliance and blood volume Diastolic blood pressure
Black H. JCH 2003; 5:12

PATHOPHYSIOLOGICAL CHARACTERISTICS

Arterial Wall Compliance and Pulse Pressure Wave

Elastic Vessel Systole Diastole Stroke Volume Stiff Vessel Systole Diastole

Aorta

Resistance Arterioles Pressure (Flow)

Young Artery
Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.

Arteriosclerotic Artery

 Lifestyle factors such as obesity, especially central adiposity, being sedentary, and eating a diet high in sodium content are also contributors commonly identified among older individuals. Older individuals experience little difficulty maintaining their blood pressure and cerebral perfusion Arterial stiffness, especially in the large arteries, is the pathophysiological characteristic that best exemplifies geriatric hypertension

 It is directly related to the increase in peripheral vascular resistance, a pathognomonic characteristic of hypertension in the elderly population. In addition to age and body mass index, insulin resistance also appears to be independently related to increased arterial stiffness. The connection between arterial stiffness and the type of hypertension most commonly encountered in older patients, namely, systolic hypertension with high pulse pressure

 Beyond this structural change in the arteries, the regulation of vascular resistance is also affected by age-related changes in the autonomic nervous system and in the vascular endothelium. There is an age-associated decline in the sensitivity of the arterial baroreceptor. This effects the regulation of vascular resistance in two important ways.

 First, a larger change in blood pressure is required to stimulate the baroreceptor to invoke the appropriate compensatory response in heart rate. This also contributes to the age-related increase in blood pressure variability. Second, the decrease in baroreceptor sensitivity leads to relatively greater activation of sympathetic nervous system outflow for a given level of blood pressure.

 An age-associated increase in sympathetic nervous system activity has been demonstrated by higher plasma norepinephrine levels, rates of norepinephrine release In older hypertensive subjects, arterial alphaadrenergic receptor responsiveness has been shown to be elevated in relation to their high level of sympathetic nervous system activity possibly contributing to their higher blood pressure. Regulation of vascular resistance by the vascular endothelium is also changed in relation to age.

 Endothelial dysfunction demonstrated by a decrease in the production of endothelial-derived nitric oxide has been identified to accompany aging aswell as hypertension Age-related changes in renal function and in particular in renal regulation of sodium balance may also contribute to an increase in blood pressure Aging also alters the reninangiotensinaldosterone system in ways that may contribute both to elevated blood pressure as well as sodium sensitivity

DIAGNOSTIC EVALUATION
Standard measurement instructions dictating cuff size and type of instrument Several factors regarding appropriate blood pressure measurement First, as a result of the observation that blood pressure is more variable in older people: hypertension should never be diagnosed on the basis of a single blood pressure measurement The diagnosis of hypertension should be based on the average of a minimum of nine blood pressure readings that have been obtained on three separate visits

 Second, there is a strong association between arterial stiffness and the presence of an auscultatory gap. For this reason, if the blood pressure cuff is initially not inflated to a pressure above the true systolic pressure but falls within the range of the individuals auscultatory gap, the systolic pressure will be underestimated

 Third, while not directly related to the diagnostic classification of hypertension, another important factor in blood pressure measurement is to always obtain supine and upright standing readings to determine if there is evidence for an orthostatic or postural decrease in blood pressure Fourth, some individuals may have in-office blood pressure readings that are markedly elevated compared with their in-home, selftaken readings, commonly referred to as white coat hypertension

Clinical Manifestations
Physical exam: Abdomen Funduscopic Vascular Cardiac Pulmonary Neurological Lab tests: Urinalysis Blood Chemistry ECG Renal ultrasound Echocardiogram Vascular studies

Target Organ Damage and Risk Factor Assessment

The evaluation should also include a determination of target organ damage and a cardiovascular risk factor assessment and identification of comorbid conditions that may impact antihypertensive Drug selection important to assess whether the patient has evidence of renal impairment, proteinuria, hypertensive retinopathy, electrocardiographic abnormalities or left ventricular hypertrophy. An assessment of overall cardiovascular risksmoking history, alcohol intake, dietary salt and fat intake, and level of physical activityshould also be completed

APPROACH TO TREATMENT
The general recommended target (for patients without diabetes or chronic kidney disease) is to decrease systolic blood pressure below 140 mmHg and diastolic blood pressure below 90 mmHg utilizing therapies that are least likely to produce adverse side effects or have a negative impact on quality of life.
The goal for patients with diabetes or chronic kidney disease is a systolic blood pressure level below 130 mmHg.

 The most common treatment-related adverse side effect, shared by all antihypertensive medications, is the development of postural hypotension. Patients may present with atypical symptoms such as generalized weakness or fatigue rather than noting postural lightheadedness or dizziness. For this reason, it is important not to treat blood pressure too aggressively and also to always determine supine and upright blood pressure measurements during monitoring of all older patients

Management
Primary goal is to reduce cardiovascular and renal morbidity and mortality. Other keys to management are: Prevention Patient education Life-style modification Medication

Hospitalization should be considered if

Very high BP
Severe headache Chest pain Neurologic symptoms Altered mental status Acutely worsening renal failure S & S of hypertensive emergency

Pharmacological Therapies

Special Considerations When Treating HT JNC 7 recommendations for treating hypertension are similar in the general population and older persons. (1) treat isolated SBP. (2) thiazide diuretics should be first line treatment.

(3) second-line treatment should be based on comorbidities and risk factors.

Special Considerations When Treating HT (4) patients with SBP higher than 160 mm Hg or DBP higher than 100 mm Hg usually will require two or more agents to reach goal. (5) treatment should be initiated with a low dose of the chosen antihypertensive agent, and titrated slowly to minimize side effects such as orthostatic hypotension.

Special Considerations When Treating HT

(6) weight loss and sodium reduction have been shown to be feasible and effective interventions in older patients with HT. - recommended lifestyle modifications. - JNC 7 recommends adoption of the Dietary Approaches to Stop Hypertension (DASH) diet, which has been shown to produce blood pressure reductions similar to single-drug therapy.
- Randomized controlled trial of nonpharmacologic interventions in the elderly (TONE) [published erratum appears in JAMA 1998;279:1954]. JAMA 1998;279:839-46. - Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med 2001;344:3-10.

Special Considerations When Treating HT (7) to improve adherence with antihypertensive regimens - involve patients in goal setting. - ensure the patients cultural beliefs and previous experiences are incorporated in a treatment plan. - simplify the medication regimen. - keeping in mind how much it costs.

Differential Diagnosis
1. Rule out isolated incident of increased blood pressure. 2. Rule out secondary hypertension related to: Renal disease Cushing's disease Pheochromocytoma Hyperthyroidism Hyperparathyroidism

Complications
Complications as a result of HTN include:
Stroke Dementia Myocardial Infarction Congestive Heart Failure Retinal Vasculopathy Aortic Dissection Renal Disease or Failure

Treatment Recommendations for the Elderly in JNC 7

Recommendations are no different according to age for: BP classification

BP goals
Lifestyle interventions

Selection of medications

JNC 7: New Features and Key Messages

For persons over age 50, SBP is a more important than DBP as CVD risk factor. Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.

Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.

Thank You