Dr. Gibson is associate professor, Department of Family Medicine, Medical University of South Carolina, Charleston.

Dr. Fritz is a senior resident at the Trident/MUSC Family Medicine residency program, Charleston.

Mr. Kachur is a graduate student at the University of West Georgia, Carrollton, Georgia.

ABSTRACT

The elderly are the fastest-growing population with the highest prevalence of hypertension. The major factors contributing to poor blood pressure control include inadequate intensity of treatment, suboptimal drug regimens, high prevalence of resistant hypertension, poor adherence to pharmacotherapy and lifestyle changes, and higher prevalence of concomitant metabolic and cardiovascular complications in older persons. Key strategies for hypertension treatment in elderly include lifestyle changes and hypertension treatment until target BP goal is reached with mono or combination therapy. Thiazide diuretics as first-line therapy are preferred for most uncomplicated hypertensive patients and in conjunction with other agents in patients with high cardiovascular risks or diabetes. Combination therapy should be offered early in the treatment in the presence of subclinical organ damage, cardiovascular disease, renal disease, or diabetes with low doses titrated gradually with regular monitoring for side effects and adherence to therapy.

Gibson MV, Fritz J, Kachur V. Practical strategies for management of hypertension in the elderly. Geriatrics. 2009;64(10):10-19.

Key words: aging, adherence to therapy, blood pressure, combination therapy, elderly, resistant hypertension

Drugs discussed: aliskiren, amlodipine, chlorthalidone, cyclosporine, diltiazem, erythropoietin, felodipine, hydralazine, minoxidil, modafinil, nifedipine, spironolactone, torsemide, triamterene/hydrochlorothiazide, verapamil

The number of persons aged 60 years and over has tripled over the last 50 years and will more than triple again during the next 50 years. The elderly account for 17.8% of the US population, are one of the fastest-growing demographic segments, and have the highest prevalence of hypertension.^1,2 In the Framingham cohort study, the prevalence of hypertension climbed from 27% among participants younger than 60 years old to 74% in people aged 80 years or older. Among the patients aged 80 years and older, fewer than 10% had blood pressure (BP) levels less than 140/90 mm Hg.³ The World Health Organization has indicated that increased BP is a leading risk factor for death, predicts an epidemic of hypertension, and is advocating prevention and treatment programs as priorities.⁴

An investigation of patterns of hypertension outcomes in Framingham Heart Study participants demonstrated that, with advancing age, absolute risks for cardiovascular events associated with hypertension increase markedly, especially among the oldest participants with hypertension.³

In one study of 600,000 patients, up to 66% of deaths from cardiovascular disease (CVD) were related to hypertension.⁵ In another study of 19,390 patients followed for 30 years, uncontrolled BP (≥160/≥95 mm Hg) resulted in a 47% increased risk of CVD-related death in men and a 70% increased risk in women compared with patients whose hypertension was treated and controlled.⁶ About 69% of people who have a first heart attack, 77% who have a first stroke, and 74% who have chronic heart failure have BP greater than 140/90 mm Hg.² Currently estimated direct and indirect cost of hypertension for 2009 is $73.4 billion.²

Benefits of hypertension treatment in elderly

Isolated systolic hypertension (ISH) is more closely related to cardiovascular risk than diastolic hypertension and is much more common in the elderly. The magnitude of preventive benefits from antihypertensive therapy depends on cardiovascular and metabolic risk factors. Based on one systematic review of 15 trials that included 21,908 patients with hypertension at least 60 years old, the number needed to treat for 5 years was 52.6 to prevent 1 cardiovascular death and 55.6 to prevent 1 overall death.⁷ New results of the HYpertension in the Very Elderly Trial (HYVET) indicated that in patients older than 80 years, antihypertensive treatment not only reduced the rate of stroke by 34% and the rate of death from stroke by 45% but also reduced the rate of heart failure by 72%, the rate of death from cardiovascular causes by 27%, and the rate of death from any cause by 28%.⁸ In an analysis including 918 Medicare recipients (mean age, 76.3 years), hypertension appeared to increase the risk of mild cognitive impairment, primarily the nonamnestic form, most likely because of concomitant cerebrovascular disease. The analysis concluded that prevention and treatment of hypertension may have an important effect in lowering the risk of cognitive impairment.⁹ According to a recent study of 525 patients (mean age, 65 years), hypertension may account for one-tenth of cognitive impairment cases and therefore, may contribute to increased risk for dementia.¹⁰ However, a review of trials including 12,091 patients with hypertension who were treated with either medication or lifestyle strategies for at least 6 months and followed for 5 years did not find convincing evidence that lowering BP prevents the development of dementia or cognitive impairment in patients without prior cerebrovascular disease.¹¹ This finding was confirmed in a study of 782 patients ranging from 90 to 108 years old.¹² Further research is needed to clarify the role of antihypertensive therapy on cognitive function in older populations.