Blood pressure control essential for elderly patients
■ A column about treating a growing demographic
By Beatriz Korc, MD — is a practicing geriatrician and director of clinical services in the Dept. of Geriatrics and Adult Development at the Mt. Sinai School of Medicine in New York. By , Susan J. Landers — is a longtime staff member. She covered medical schools, residencies, scope of practice, continuing medical education, work force issues and public health. Posted Dec. 7, 2009.
Mrs. Harvey, 85, comes to your office every three to four months for follow-up on a range of conditions. Although her blood pressure had been normal, it was high during her most recent visit. Before considering medication, you decided to monitor her BP for a month. Her daughter, a nurse, volunteered to do this at home. They report the following readings: systolic pressure ranged from the 150s to 170s mmHg and diastolic pressure ranged from the 70s to 80s mmHg. You need to decide whether this patient should be on antihypertensives, and if so, which one(s) and at what doses.
Mrs. Harvey also has osteoarthritis, hypothyroidism and depression, for which she takes 100 mg celecoxib twice daily; 100 mg sertraline once daily; and 88 micrograms levothyroxine once daily. She takes two tablets of 500 mg acetaminophen every eight hours, if needed, for joint pain.
Historically, there have been conflicting data regarding the safety and efficacy of treating hypertension in the very elderly. Physicians were unsure about whether this population could derive the same benefit from treatment as do younger people.
Hypertension was often considered one of the inexorable consequences of aging and, therefore, many older patients were not treated adequately. In addition, it was not known at what blood pressure level treatment should begin and what level should be achieved.
Today, it has been well documented that the risk of death from ischemic heart disease and stroke increases with elevated blood pressure, and the increased risks are present in people of all ages.
Hypertension is common in the elderly. Data from the long-running Framingham Heart Study show that people with normal blood pressure readings at age 55 have a 90% lifetime risk for developing hypertension.
The Framinghan study, supported by the National Heart, Lung and Blood Institute and Boston University, was launched in 1948 and now includes three generations of families.
Investigators reported that the relationship between elevated blood pressure and cardiovascular disease is continuous, consistent and independent of other risk factors. The higher the blood pressure, the greater the chance of heart failure, stroke and kidney disease.
Isolated systolic hypertension represents the most common form of hypertension for people older than 50. Results from the Systolic Hypertension in the Elderly Program, which were reported in the Journal of the American Medical Association in 1991, demonstrated that control of this form of hypertension reduced the incidence of stroke and major cardiovascular events in older adults.
In 2003, new recommendations were released in the "Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure" calling for lower blood pressure readings for all age groups. The new guidelines note that therapy should not be withheld on the basis of age.
But it was the large 2008 study, the Hypertension in the Very Elderly Trial, that provided the strongest evidence that antihypertensive treatment helped people older than 80. HYVET was a randomized, double-blind, placebo-controlled study conducted in sites in Europe, China, Australia and Tunisia. It is the largest clinical trial to address the question of treatment in the elderly.
Nearly 4,000 patients, with a mean age of 84 and mean blood pressure of 173/91, were enrolled. Active treatment was with 1.5 mg indapamide SR, with the addition of 2 mg to 4 mg of perindopril, if necessary, to reach a target blood pressure of 150/80. Strokes were the primary end point.
After two years of treatment, mean blood pressure while seated was 15.0/6.1 lower in participants who took the medications than in those given placebo. Treatment was associated with a 30% reduction in strokes, both fatal and nonfatal; 21% reduction in death from any cause; 23% reduction in death from cardiovascular causes and 64% reduction in the rate of heart failure. The results strongly support a target blood pressure of 150/80 in this age group. The benefit of further reduction still needs to be established.
For Mrs. Harvey and other elderly patients, obtaining accurate and representative blood pressure readings can be difficult. Blood pressure is often more variable among older adults and exaggerated drops may occur when standing from a seated position or after a meal. Evaluation of elderly patients with suspected hypertension should include blood pressure measurements while seated and while standing. Diagnosis should be based on two or more high readings at separate visits.
A medical history should also be taken, including cardiac risk factors and other aggravating factors such as smoking, obesity, diabetes, dyslipidemia, excessive alcohol or salt intake, and emotional stress.
During physical exam, attention must also be paid to signs of organ damage, such as hypertensive retinopathy. The exam should include the heart and peripheral arterial pulses as well as auscultation of the carotid arteries and abdomen for bruits.
Routine lab tests should include urinalysis, complete blood count, fasting glucose levels, electrolyte panel, creatinine level and lipid profile. An electrocardiogram also should be ordered.
Nonpharmacological treatment also can be as beneficial in the elderly as it is with younger people and could include counseling on smoking cessation, alcohol intake, reduction of dietary sodium, weight reduction and increased aerobic exercise.
Drug classes used to reduce blood pressure in older people who have no comorbidities are often the same as those used for younger people. Therapy with two or more drugs is frequently needed to achieve a goal. A thiazide diuretic, beta-blocker or ACE inhibitor can be used as a first-line drug. However, as with any other medication for elderly patients, the key is to start low and go slow. Monitoring for postural hypotension and other reactions also is advised.
Also consider side effects. If a patient already has incontinence, for instance, she may be unwilling to take a diuretic. The starting dose of hydrochlorothiazide in a patient like Mrs. Harvey should be no higher than 12.5 mg a day.
Due to changes in age-related pharmacodynamics, older patients are also more sensitive to beta-blockers, showing a higher incidence of bradycardia, which can result in dizziness and falls. An initial dose of an extended-release tablet of metoprolol should be no higher than 25 mg a day. ACE inhibitors, such as lisinopril, may be started at a dose of 2.5 mg a day. Calcium channel blockers, such as amlodipine, may also be a safe choice, starting with 2.5 mg a day.
Follow-up should be monthly until a blood pressure goal is reached. After that, a visit every three to four months is appropriate to monitor Mrs. Harvey and patients like her, to ensure the stable blood pressure is maintained.
Beatriz Korc, MD is a practicing geriatrician and director of clinical services in the Dept. of Geriatrics and Adult Development at the Mt. Sinai School of Medicine in New York. , Susan J. Landers is a longtime staff member. She covered medical schools, residencies, scope of practice, continuing medical education, work force issues and public health.