The Art of Blood Pressure Management in the Elderly

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The Art of Blood Pressure Management in the
Elderly

• Dr. Sheri-Lynn Kane
• St. Josephs Health Centre,Guelph
• Geriatrician
• Assistant Clinical Professor McMaster University

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Overview

• Why do we treat hypertension?
• Why not just apply the evidence to everyone?
• Special considerations in the elderly

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The Oldest-Old Boomsource Stats Can 2002
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Physiological Changes with Aging

• Increased vessel stiffness ? decrease arterial
  compliance
• Decreased baroreceptor sensitivity
• ? in ß vasodilatation / a vasoconstriction
  balance favours vasoconstriction
• ? ability to handle salt

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Changes with Aging

• Results in high prevalence of both
• Combined hypertension gt 140/90
• Isolated systolic hypertension gt160 DBP lt95

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End Organ Morbidity

• Cardiovascular
• MI
• CHF diastolic and systolic
• PVD
• Cerebrovascular
• Dementia Mild cognitive impairment
• Stroke hem and non-hem
• Ocular disease
• Renal failure

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Treatment

• Trials in the elderly significantly
• ? rate of stroke
• ? rate of CHF /CV end-point
• ? rate of dementia / cognitive impairment
• Strong evidence for midlife hypertension linked
  to cognitive decline

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So why not just aim for target BPs in everyone?

• Evidence to date in those 85 variable
• Many prospective, longitudinal studies show ?
  mortality with normal or low BPs 85 years
• Those 85 yrs represents highly variable
  population ? generalizability
• Special considerations of BP in elderly

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• Who 80 yr with SBP 160 DBP 110 mmHg
• Eastern Europe, China
• Not accelerated HTN, CHF, dementia, nursing
  care, ? potassium, Cr gt 150, gout

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• What DBPC, randomized, ITT
• Indapamide SR 1.5mg perindopril 2 or 4
• target STANDING SBP lt150 DBPlt80 mmHg
• Outcome fatal or nonfatal stroke
• death all cause, CV death, death CHF

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Bottom line

• Curve shifts with the very old for normal
• Still can decrease rate of stroke and CHF if
  applied to the right people
• Need to be monitored more carefully to keep in
  optimal range
• Dementia data pending

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Special considerations

• 87yo ? lives alone
• 3 falls in the last 6 months, pelvic F
• HTN since 70s, difficult to control
• No previous MI/stroke/TIA/CHF
• LVH by voltage ECG

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• Meds
• Eltroxin 0.15mg
• ECASA 325 mg
• Ezetrol 10 mg od
• Crestor 10 mg od
• Pindolol 5 mg od
• HCTZ 25 od

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Orthostatic Hypotension

• Definition
• ? of 20/10mmHg SBP/DBP from supine to standing
  at 2 minutes
• Prevalence
• 20 gt 65 yrs community
• 30 gt75 yrs community
• 50 in frail institution
• Assoc with post-priandial hypotension

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Orthostatic Hypotension

• ? Autonomic or non-autonomic
• ?Symptomatic or asymptomatic
• Consequences
• Falls / fractures
• Syncope
• TIA
• MI
• Frailty /weight loss
• ? mortality

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• 87yo ? lives alone
• 3 falls in the last 6 months, pelvic F
• HTN since 70s, difficult to control
• No previous MI/stroke/TIA/CHF
• LVH by voltage ECG
• Meds
• Eltroxin 0.15mg
• ECASA 325 mg
• Ezetrol 10 mg
• Crestor
• Pindolol 5 mg od
• HCTZ 25 od

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Special considerations

• 80 yo? lives alone
• Longstanding refractory hypertension
• Meds
• Altace 10mg od
• Norvasc 5 mg bid - ?to bid 3 months ago
• HCTZ 25mg od
• BP 188/88 both arms in any position, light headed
  with standing
• Feels awful, multiple falls, losing weight

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Pseudohypertension

• Defn
• Artificial elevation of BP when measured by
  indirect cuff vs intra-arterial
• Often associated with some hypertension
• Due to stiff calcified vessels

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What to do?

• 80 yo? lives alone
• Longstanding refractory hypertension
• Meds
• Altace 10mg od
• Norvasc 5 mg bid - ?to bid 3 months ago
• HCTZ 25mg od
• BP 188/88 both arms in any position, light headed
  with standing
• Feels awful, multiple falls, losing weight

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Loss of diurnal variations

• 20 HTN are non-dippers
• gt 50 of those with orthostatic hypotension
• Cardiovascular events/100 pt-yr
• 1.79 HTN dippers
• 4.99 HTN non-dippers
• 0.47 normotensive
• Ambulatory BP helpful

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Summary

• Need orthostatic BPs in everyone
• May need ambulatory monitoring
• Need adequate control for degree of end organ
  damage
• Titrate slowly one at a time on/off
• Need more frequent monitoring
• Need to avoid excessive lows especially 85yr /
  frail