Hypertension in the Elderly: Should it be Treated, and How?

Editor's Note: Hypertension (defined as a blood pressure over 140/90 mm Hg) affects more than two out of three individuals over 75 years of age. There has been a misconception that hypertension in the elderly should not be treated with anti-hypertensive medications. This misconception is driven by the notion that a normal systolic pressure is "100 plus your age." In other words, in a 75 year old person a systolic blood pressure of <175 mmHg should be considered normal. While it is true that hypertension needs to be carefully managed in the elderly, because too rapid a lowering might not be tolerated, the consensus is that hypertension in the elderly should be treated. 

Recently, the American College of Cardiology Foundation Task Force on Clinical Expert Consensus developed a report on hypertension in the elderly. This report represented a collaboration between the American College of Cardiology, the American Academy of Neurology, the American Geriatrics Society, the American Society for Preventive Cardiology, the American Society of Hypertension, the American Society of Nephrology, the Association of Black Cardiologists, and the European Society of Hypertension.

George Bakris was a writing member of this committee. I invited him to provide us with a commentary on the key conclusions.

Dr. George Bakris is Professor of Medicine and Director of the Hypertension Center at the University of Chicago. Dr. Bakris has published over 500 articles and book chapters in the areas of diabetic kidney disease, hypertension and progression of nephropathy. He is the Editor or Co-Editor of eight books, in the areas of Kidney Disease Progression and Diabetes. He chaired the first National Kidney Foundation Consensus report on blood pressure and impact on renal disease progression (2000). He has also served on many national guideline committees including: JNC VI & VII writing committees (1997, 2003). Dr. Bakris is also the past- president of the American College of Clinical Pharmacology (2000-2002) and the current President of the American Society of Hypertension (ASH)-(2010-2012). He is the current Editor of Am J Nephrology, the Hypertension Section Editor of Up-to-Date, and an Associate Editor of Diabetes Care.

COMMENTARY -Dr. George Bakris

Expert Consensus on Hypertension in the Elderly: A Summary from the Report of the American College of Cardiology Foundation Task Force on Expert Consensus 

The United States population is aging, and as hypertension affects most elderly people over 65 years; these individuals are more likely to have organ damage or clinical cardiovascular (CV) disease. They represent management dilemmas because most hypertension trials limit recruitment by age or do not present age-specific results. With the advent of the Hypertension in the Very Elderly Trial (HYVET) documenting antihypertensive therapy benefits in persons 80 years or older, it is timely to place into perspective issues relevant to hypertension management in elderly patients.

The report is quite extensive and covers many trials focused on patients with a mean age of > 65 years [1]. All aspects of disease from risk factors to pathophysiology as well as all aspects of non-pharmacologic and pharmacological management are discussed, in depth, in the consensus report. This summary of the report will only highlight management issues and briefly touch on other aspects discussed.

Clinical Assessment and Diagnosis

It is important in the elderly to properly measure brachial blood pressure by following the AHA guidelines i.e. at least three different BP measurements, taken on two or more separate office visits. At least two measurements should be obtained once the patient is seated comfortably for at least five minutes with the back supported, feet on the floor, arm supported in the horizontal position, and the BP cuff at heart level. Pseudohypertension is a falsely increased SBP that results from markedly sclerotic arteries that do not collapse during cuff inflation. This may lead to a diagnosis of hypertension and result in therapy that may lead to untoward side effects because of unusually low central aortic pressures.

Recommendations for Evaluation

Due to limited information for evidence-based guidelines to manage older hypertension patients, the following recommendations are based on expert opinion that we believe provide a reasonable clinical approach. Evaluation of the elderly patient with known or suspected hypertension must accurately determine BP, and if elevated: 

1) identify reversible and/or treatable causes; 

2) evaluate for organ damage; 

3) assess for other cardiovascular disease (CVD) risk factors/co-morbid conditions affecting prognosis; and 

4) identify barriers to treatment adherence. 

Evaluation includes a history, physical exam, and laboratory testing. It is most important to focus on aspects that relate to hypertension, including details concerning the duration, severity, causes or exacerbations of high BP, current and previous treatments including adverse effects, assessment of target organ damage, and other CVD risk factors and comorbidities, as noted above. There is limited evidence to support routine laboratory testing. Instead, a more deliberative reasoned approach to testing is recommended: 

1) Urinalysis for evidence of renal damage, especially albuminuria/microalbuminuria; 

2) Blood chemistries (especially potassium and creatinine with eGFR); 

3) Total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides; 

4) Fasting blood sugar (including hemoglobin A1c, if there are concerns about diabetes); and 

5) electrocardiogram (ECG). 

In selected elderly persons, 2-dimensional echocardiography is useful to evaluate for LVH and LV dysfunction that would warrant additional therapy (i.e., angiotensin-converting enzyme inhibitors [ACEIs], beta-blockers).

Hypertension Management

There are a number of factors that should be considered in elderly patients including cognitive function, financial ability to pay for medications and adverse effects related not only to medications but also to changes in cognitive function related to lower BP values.

All clinical trials reviewed demonstrate a benefit from a blood pressure of <150/80 mmHg. The general recommended BP goal in uncomplicated hypertension in the elderly with hypertension is <140/90 mmHg. However, this target for elderly hypertensives is based on expert opinion rather than on data from RCTs. All elderly hypertensive patients are candidates for nonpharmacologic interventions; if they remain hypertensive, drug therapy should be considered. An SBP goal of <140 mmHg is appropriate for most patients aged ≤79 years; for those aged ≥80 years, 140 to 145 mmHg, if tolerated, is acceptable.

Perhaps one of the most important nonpharmacologic interventions to achieve BP goals in the elderly is to restrict sodium intake to a maximum of 2.4 grams or a level teaspoon per day. The elderly are very prone to be salt sensitivity that is associated with hypertension and high blood pressure variability is associated with higher risk of cerebrovascular events.

Considerations for Drug Therapy

Initiation of Drug Therapy

The initial antihypertensive drug should be started at the lowest dose and gradually increased, depending on BP response, to the maximum tolerated dose. An achieved SBP <140 mmHg, if tolerated, is recommended except for octogenarians where pressures below a systolic of 150 mmHg is appropriate. 

If the BP response is inadequate after reaching full-tolerated dose, a second drug from another class should be added. 

If there are adverse effects or no therapeutic response, a drug from another class should be substituted. If a diuretic is not the initial drug, it is usually indicated as the second drug.

If the antihypertensive response is inadequate after reaching full doses of two classes of drugs, a third drug from another class should be added. 

When BP is more than 20/10 mmHg above goal, therapy should be initiated with 2 antihypertensive drugs. Data from some trials would suggest a blocker of the renin angiotensin system (RAS) with a calcium antagonist in the absence of heart failure; alternatives include a RAS blocker with a diuretic appropriate for kidney function. 

Treatment must be individualized in the elderly. Before adding new antihypertensive drugs, possible reasons for inadequate BP response should be examined. On average, elderly patients are taking more than six prescription drugs, so polypharmacy, non-adherence, and potential drug interactions are important concerns.

References

1. Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Forciea MA, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ, Harrington RA: ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation 2011;123:2434-2506.