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TREATMENT OF HYPERTENSION IN ELDERLY PATIENTS 2014

Ass. Professor Nguyen Van Tri, MD, PhD


President of Geriatric Association of Ho Chi Minh City
Head of the Department of Geriatrics and Gerontology
University of Medicine and Pharmacy
Ho Chi Minh City - VIETNAM
I. THE GENERAL PRINCIPLE
- Treatment is based on the principle of pathology triangle of the elderly.
Hypertension

Degree of aging
-

Comorbidities

Put the patient in the center to determine the benefits and side effects of antihypertensive
treatment, thereby determining the target blood pressure and which medication needed to
treat, mono-therapy or coordination.

II. THE DEGREE OF AGING


- When evaluating the degree of aging, keep in mind two kinds of age category
o Chronological age: Elderly in Vietnam is 60 years old or more
60 69 : young old
70 79 : old old
80 and more: oldest old
o Biological age: The level of physical and mental activity daily (also called functional
daily activities)
o Combining chronological age and biological age to determine the degree of aging.
- The degree of aging is divided into 3 levels:
o Healthy aging (successful or fit)
o Frail: including subclinical weakening (asymptomatic) to severe impairments
Physical impairments including daily physical activities from self-care to occupati
onal activities
Mental impairments mainly in many degrees of memory deficits (memory
disorders, dementia, Alzheimer's)
o End-of-life stage: with expected 1-2 final years of life

For healthy aging, blood pressure control can be achieved the same as adults (< 60 years
of age). Avoid symptoms of postural hypotension.
For frail patients, setting target blood pressure depends on the degree of clinical
impairment, the best is around systolic 140-145 mmHg. Monitoring closely for symptoms
of postural hypotension.
For end-of-life stage, mainly palliative care, avoid hypertensive crisis, avoid hypotension.
Minimum antihypertensive drugs if possible.

III. COMORBIDITIES
- Elderly hypertensive patients often have comorbidities including chronic complications
of hypertension such as coronary artery disease, chronic heart failure, chronic kidney
disease; risk factors such as diabetes, sedentary.. ; and comorbidities like osteoarthritis...
- Pay attention to comorbidities to specify which antihypertensive medication is the most
appropriate (also called mandatory indication).
IV. THE IMPORTANT NOTES
Always remember the triangle disease in elderly patients: hypertension - comorbidities the degree of aging.
Take the patient in the center to choose the target blood pressure, and which medication.
Start with a low dose, increase the dose slowly.
Avoid symptoms of postural hypotension, never let systolic < 120 mmHg and diastolic <
60 mmHg.
All current antihypertensive drugs can be used depending on the comorbidities.
If there are no comorbidities, appropriate drugs for the elderly consist of three: diuretics,
calcium channel blockers, and inhibition of the reninangiotensin system (RAAS).
V. MEDICATIONS
Diuretic

RAAS blockers

Calcium channel blocker

Diuretics. Thiazide-type diuretics are recognized as the cornerstone of antihypertensive


therapy because of their extensive record in preventing stroke and cardiovascular events
and their low cost. However, questions have been raised about dosing and about the long-

term consequences of their adverse metabolic effects. Although "low-dose" thiazide-type


diuretics are generally recommended for BP treatment, outcome benefits of diuretics as
first-line agents have been demonstrated only at moderate doses (equivalent to 25 mg
hydrochlorothiazide). There are no outcome data for truly "low-dose" thiazides
(equivalent to 12.5 mg hydrochlorothiazide). Further, most outcome trials in the United
States, including ALLHAT, have used chlorthalidone, a thiazide-like diuretic that is twice
as potent as and has a longer duration of action than hydrochlorothiazide. In ALLHAT,
the average dose of chlorthalidone was 20 mg, roughly equivalent to 40 mg of
hydrochlorothiazide. On the basis of outcome trials and the observation that it is more
effective than hydrochlorothiazide in lowering 24-hr systolic BPs, chlorthalidone
deserves consideration in the treatment of hypertension in the elderly.
The downside of this approach is that moderate-dose diuretic therapy increases the
incidence of hypokalemia, insulin resistance, and type 2 diabetes. Outcome trials have
not shown that diuretic-induced diabetes is associated with cardiovascular disease
outcome, but it has been argued that this is an artifact related to their short (< 5 years)
duration of follow-up. Extended observation of participants in ALLHAT and other trials
is ongoing in an effort to address this issue.
CCBs. These agents have performed particularly well in preventing stroke in elderly
hypertensives. A recent meta-analysis found that dihydropyridine CCBs reduce stroke by
10% compared with other active therapies. Much of this advantage may be related to their
robust BP-lowering effects, which were evident in both the Antihypertensive Long-term
Use Evaluation (VALUE) and ASCOT trials, where 4-5 mm Hg lower brachial artery
systolic BP levels were noted in the first few months of CCB-based therapy compared
with ARB- or beta-blocker-based treatment. The BP differences contributed to, but may
not have fully accounted for, the superior outcome results of CCB treatment in these
trials. CCBs are metabolically neutral and, except for peripheral edema, are relatively
free of adverse effects. In principle, the lack of adverse metabolic effects may represent a
major advantage of CCBs over diuretics for a population in which the metabolic
syndrome/insulin resistance is becoming epidemic. However, this theoretical advantage
has yet to be substantiated in clinical trials.
On the basis of BP-lowering efficacy and outcomes data, CCBs are acceptable
alternatives to diuretics for first-line treatment of hypertension in the elderly and may
offer advantages in some patient groups, eg, those with the metabolic syndrome. While
acquisition costs are substantially greater for CCBs than for diuretics and some other
drug classes, drug costs represent only a fraction of the total cost of care of the
hypertensive patient. We await cost-benefit analyses from large trials such as ALLHAT
and ASCOT to fully assess the pros and cons of first-line CCB vs diuretic therapy in the
elderly hypertensive.
ACE Inhibitors and ARBs. These antihypertensive drug classes have outcome
advantages for patients with concomitant cardiovascular diseases, diabetes with
albuminuria, or chronic kidney disease. When administered alone or in combination with
other antihypertensive drugs, ACE inhibitors and ARBs reduce the incidence of newonset diabetes by about 25% compared with other active treatments, a clear advantage in
the elderly. Further, except for ACE inhibitor-induced cough, they are better tolerated

than other drug classes. However, these agents have less robust BP-lowering effects than
CCBs and diuretics in the elderly, likely because of their volume-expanded/reninsuppressed state. As shown in ALLHAT and VALUE, these renin-angiotensin system
antagonists have less favorable outcomes than diuretics or CCBs when used as initial
therapy in the elderly hypertensive. They are most useful in combination therapy with a
diuretic or CCB.
Other Drug Classes. Beta-blockers, adrenergic blockers, centrally acting agents, direct
vasodilators, and mineralocorticoid (aldosterone) receptor antagonists are useful in
lowering BP and in treating some forms of target organ damage/concomitant conditions
in elderly hypertension, particularly when used in combination with the agents discussed
above. However, these drug classes lack outcomes data to support their use as first-line
treatment of uncomplicated hypertension in the elderly.
VI.

Lifestyle Modifications. Weight loss for most patients, and increased physical activity
for all, are effective in reducing BP in elderly patients who are adherent to
exercise/dietary prescription. Dietary modification and moderation of alcohol intake, as
indicated are also helpful. These measures are indicated for all hypertensive persons,
because they are effective in reducing cardiovascular risk factors and they enhance the
efficacy of pharmacologic treatment.

VII.
-

TESTS IN THE ELDERLY


Electrolytes, especially when the patient is taking diuretics and RAAS blockers or has
abnormal renal function.
Glomerular filtration rate (GFR) because many elderly patients have decreased GFR,
even though serum creatinine is in the normal range.

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