Geriatric Population

1
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2
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3
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• ???????????????? gt 60
• ???????????????????? gt 65

4
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5
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???????? ???????? ?.?. ???????
1 2453 8,266,408
2 2462 9,207,355
3 2472 11,506,207
4 2480 14,464,105
5 2490 17,442,689
6 2503 26,257,916
7 2513 34,397,371
8 2523 44,824,540
9 2533 54,548,530
10 2543 60,916,441
- 2552 63,395,600
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2553-2543 ?????????????????????
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?? ?.?. 2548-2568. ??????
????????????????, 2549.
6
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??????????? 1. ?.?. 2480, 2490, 2503
Rungpitarangsi (1974) 2.
?.?. 2507-2508, 2517-2519, 2528-2529, 2532, 2534,
2538-2539 ???????????????????????????????
???????, ?????????????????????
3. ?.?. 2549 ??????????????????????????????????
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7
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8
??????????????? ?.?. 2506-2526 ???????????????????
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???????????????????????????? ?.?. 2548
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(??????????). ??????????????? 2548.
9
???????????????????????? ?.?. 2500 ???
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??????????? 17 ?????? ?.?. 2513
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10
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????? 50 ?????? ??????????????????????????????? 6
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1.5 ??????????
??????????? ?.?. 2507 2517 2528 ??? 2534
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?.?. 2539 ??????????????????????
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11
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2513
2552
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12
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13
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(????????????????????? ????, ????, ????, 2545)
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???????????? ?.?. 2548 2658
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14
???????? ?.?.2563-64 ?????????????????????????????
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26.9
25.1
23.0
22.7
20.7
19.8
19.0
16.8
17.2
16.0
15.1
66.0
64.1
62.2
60.5
66.7
67.4
67.0
14.4
14.0
13.8
11.8
10.3
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15
???????????????????????

• ????????????????71-96 ??
• ?????????????????????????????????
• ??????????gt 160/95 mmHg
• ??????????????140-159 mmHg
• Normotensive 39.4
• Borderline isolated HT 26.6
• Isolated systolic HT 13.2
• Diastolic HT 9.5
• Mixed 9.3

16
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200 180 160 140 120
HEART RATE (HEART BEATS/MINUTE)
Men Women
Heart Rate 220 Age (yr)
20 40 60 80
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Cardiovascular

• Stroke volume dependent cardiac output
• Syncope when change of posture
• Atrial fibrillation

• maximal heart rate 220-age
• HR response to postural stress, valsava manouer
  
• Atrial fibrosis

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Myocardial Fiber Responsiveness
Ventricular Filling (Venous Return)
Intrinsic Rhythmicity
Autonomic Regulation
Heart Rate
Stroke Volume
Cardiac Output
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???????????????????????????????

• ???????????????????
• ??????????????????????????????????????????
• ?????????????????????????????????????Decrease in
  baro- receptor

• vasoconstriction and increase peripheral
  resistance
• Decrease in heart rate adaptation with postural
  changes

21
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• ?????????????????? 70 ??????
• ??? 42???????????? HT
• ???? ? ??????????????

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?????????? HT ????????????????????????????????????
??????????

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Initial Evaluation of Hypertension in Older Adults

• History
• Duration
• Severity
• Treatment
• Complications
• Other risk factors

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Initial Evaluation of Hypertension in Older Adults

• Physical examination
• Blood pressure both arms, including Osler
  maneuver and standing determinations
• Fundoscopic, vascular, and cardiac examination
  for end-organ damage
• Abdominal bruit
• Neurological examination for focal deficits

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Initial Evaluation of Hypertension in Older Adults

• Laboratory tests
• Urinalysis
• Electrolytes
• Creatinine
• Calcium
• Chest radiograph
• Electrocardiogram

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PseudohypertensionOsler maneuver

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PseudohypertensionOsler maneuver

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Secondary hypertensionin older persons

• Renovascular disease (atherosclerotic)
• Primary hyperaldosteronism
• Hyperparathyroidism (calcium)
• Estrogen administration
• Renal disease (decreased creatinine clearance)

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???????????????????Goals of treatment

• Systolic blood pressure 135-140 mmHg
• Diastolic BP 85 mmHg

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Hypertension in the Elderly
Systolic blood pressure (mmHg)
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Lifestyle Modifications to Manage hypertension
Modifications Recommendation Approximate systolic blood pressure reduction (range)
Weight reduction Maintain normal body weight (body mass index 18.5 to 24.9 kg per m2) 5 to 20 mmHg per 10-kg weight loss
Adoption of DASH eating plan Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat. 8 to 14 mmHg
AFP 2005 71 (3)
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Lifestyle Modifications to Manage Hypertension
Modifications Recommendation Approximate systolic blood pressure reduction (range)
Dietary sodium restriction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). 2 to 8 mmHg
Physical activity Engage in regular aerobic activity such as brisk walking (at least 30 minutes per day, most days of the week). 4 to 9 mmHg
AFP 2005 71 (3)
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Lifestyle Modifications to Manage hypertension
Modifications Recommendation Approximate systolic blood pressure reduction (range)
Moderation of alcohol consumption Limit consumption to no more than two drinks (1 oz or 30 ml. of alcohol 24-oz beer, 10 oz of wine, or 3 oz of 80-proof whiskey) per day in most men and to no more than one drink per day in women and lighter weight persons. 2 to 4 mmHg
DASH Dietary Approaches to Stop Hypertension
- For overall cardiovascular risk reduction, stop
smoking - The effects of implementing these
modifications are dose and time dependent and
could be greater for some individuals.
AFP 2005 71 (3)
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First line therapy low-dose thiazide
diuretics
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Second line therapy

• Angiotensin converting enzyme inhibitors
• Calcium channel blockers
• Beta blockers

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Antihypertensive medications
Agent Advantages Disadvantages
Beta-blockers Useful in angina, previous myocardial infarction, heart failure Water-soluble agents have fewer central nervous system side effects Must be withdrawn slowly in presence of coronary artery disease Contraindicated in cardiac conduction defects and reactive airways disease May cause bronchospasm, bradycardia, impaired peripheral circulation, fatigue, and decreased exercise tolerance Claudication
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Special Precaution with Antihypertensives
Drug symptoms
B-Blocker HCTZ Worsening of bronchospasms, CHF Claudication Impotent inc.sugar, calcium, uric acid dec.Na, K, Mg Dehydration Urinary incontinence
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Antihypertensive medications
Agent Advantages Disadvantages
Calcium channel blockers Peripheral vasodilator Coronary blood flow maintained Potency increased with age or in systolic hypertension Headaches Sodium retention Negative inotropic effect Conduction abnormality
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Antihypertensive medications
Agent Advantages Disadvantages
Angiotensin-converting enzyme inhibitors Preload and afterload reduction Use in congestive heart failure, diabetes mellitus, other nephropathy with proteinuria Hyperkalemia Hypotension Decreased renal function Cough Angioedema
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Antihypertensive medications
Agent Advantages Disadvantages
Angiotensin-receptor antagonists Use in angiotensin -converting enzyme inhibitor-induced cough, congestive heart failure, diabetes mellitus, other nephropathy with proteinuria Hyperkalemia Angioedema (rare)
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Antihypertensive medications
Agent Advantages Disadvantages
Clonidine Increased renal perfusion Somnolence, depression Dry mouth, constipation Rarely, withdrawal hypertensive crisis
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Antihypertensive medications
Agent Advantages Disadvantages
Alpha-blockers Useful in benign prostatic hypertrophy Orthostatic hypotension
Hydralazine May be useful in systolic hypertension Reflex tachycardia, aggravation of angina Lupus-like syndrome at high dosage
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Comparison of antihypertensive agents in older
persons
Thiazide diuretics Beta blockers ACE inhibitors and ARBs Calcium channel blockers
Safety Electrolyte disturbance, especially hypokalemia Acute renal insuffuciency and dehydration Drug interactions digoxin (Lanoxin), NSAIDS Bronchospasm Drug interactions digoxin, diltiazen, verapamil Electrolyte disturbances hyperkalemia (especially in chronic kidney disease) First-dose hypotension and acute renal insufficiency Angioedema Drug interactions NSAIDS, potassium-sparing diuretics Nondihydropyridines atrioventricular block, bradycardia Dihydropyridines hypotension,reflex tachycardia Drug interactions cyclosporine , grapefruit juice
AFP 2005 71 (3)
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Comparison of antihypertensive agents in older
persons
Thiazide diuretics Beta blockers ACE inhibitors and ARBs Calcium channel blockers
Tolerability Orthostasis, sexual dysfunction Dehydration Dec.Na,K,Mg Inc.BS,cal,uric acid Sedation Depression Sexual dysfunction Cough with ACE inhibitor Peripheral edema, Constipation, Gingival hyperplasia
ACE angiotensin-converting enzyme ARBs
angiotensin-receptor blockers NSAIDS
nonsteroidal anti-inflammatory drugs.
AFP 2005 71 (3)
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Comparison of antihypertensive agents in older
persons
Thiazide diuretics Beta blockers ACE inhibitors and ARBs Calcium channel blockers
Efficacy Hypertension, isolated systolic hypertension, heart failure, diabetes, patients at high risk for cardiovascular disease recurrent stroke prevention Hypertension, heart failure, postmyocardial infarction, patients at high risk for cardiovascular disease Hypertension, heart failure postmyocardial infarction, patients at high risk for cardiovascular disease, diabetes mellitus, chronic kidney disease, and recurrent stroke prevention Hypertension, diabetes, patients at high risk for cardiovascular disease. Symptom control in chronic stable angina, ischemic heart disease, and atrial fibrillation
ACE angiotensin-converting enzyme ARBs
angiotensin-receptor blockers NSAIDS
nonsteroidal anti-inflammatory drugs.
AFP 2005 71 (3)
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Comparison of antihypertensive agents in older
persons
Thiazide diuretics Beta blockers ACE inhibitors and ARBs Calcium channel blockers
Price
Simplicity Once daily One to two times daily One to two times daily One to two times daily
ACE angiotensin-converting enzyme ARBs
angiotensin-receptor blockers NSAIDS
nonsteroidal anti-inflammatory drugs.
AFP 2005 71 (3)
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Examples of Potentially Clinically Important
Drug-Patient Interactions
Drug Patient factors Clinical implications
Diuretics Diabetes Poor nutritional status Urinary frequency, urgency Decreased glucose tolerance Increased risk of dehydration and electrolyte imbalance Incontinence may result
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Special Precaution with Antihypertensives
Drug symptoms
CCB short acting - long acting ACEI e K-sparing diuretic or K-supplement fluctuation of BP,postural hypotension fluid retention, edema hyperkalemia
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????????????????????????????????

• Beta-blocker withdrawal (angina)
• Calcium channel-blocker withdrawal (angina,
  hypertension)

52
??????????????????????????????????

• Falls ????? ???????????????? drug-induced
  orthostatic hypotension

53
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54
???????????????
????????????

• ?????????????? ???????? ??? Thiazide diuretic
  ????????????????????? / ???????? ???
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???????????????
????????????

• ????????? a receptor antagonists ???? first line
  therapy ??????????????????????????????? ????
  B.Blocker ????????????????? first line therapy
  ????????????????????

56
???????????????
?????????????????????

• ????????????????????????????????????? ???
  ?????????????????? ????? orthostatic hypotension
  ??? ??????????????? ?????
• Start low go slow

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THANK you