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Hasyim Kasim
Prof DR.Dr.Syakib Bakri
ELDERLY
> 65 YEARS
BLOOD PRESSURE CLASSIFICATION
• Patients should be seated with back supported and arm bared and
supported.
25
20
> 65
15
> 75
10
5 > 80
0
2000 2015 2030
21,9% 25,2% 35,1%
INDONESIAN ELDERLY POPULATION
( > 65 YEARS )
Ind. Cencus 1971, 1980, 1990, 1995 and 2000
10
9
8
7
6 4,75%
5 4,25%
3,88%
4 3,25% >65
2,51% years
3
2
1
0
1971 1980 1990 1995 2000 Biro Pusat Statistik
Indonesia
Aging is NOT a disease
Aging is a universal process.
Many elderly have arthritis, or
dementia, or hypertension
But not everyone gets the same
disease
Disease is not a necessary part of
aging
Principal Effects of
Aging on the Cardiovascular System
• Increased arterial stiffness
• Increased myocardial stiffness
• Impaired β-adrenergic responsiveness
• Impaired endothelial function
• Reduced sinus node function
• Decreased baroreceptor responsiveness
Systolic Hypertension
Pulse pressure increases continuously with
age
Smulyan H, Safar ME. Ann Intern Med. 2000;132:233-237.
Framingham – Study
Blood pressure and age
160
Women
150 Men
Systolic BP
140
BP (mmHg)
130
120
90
80 Men
Diastolic BP Women
70
36 41 46 51 56 61 66 71 76 81 Years age
Kannel et al 1978
SBP, But Not DBP, Increases
Throughout Life
60
Neurohormonal alterations
Decreased plasma renin activity
Decreased baroreceptor sensitivity
Glucose intolerance
Increased plasma catecholamine levels
(decreased
O L D P A R A D I G M
48.3
estimates for all cardiovascular end-points based on three large therapeutic trials (n=7929
on of systolic bloodpressure. Note that the risk increases with the level of systolic blood
ure (SBP). However, at any given value of SBP, the risk is higher when diastolic blood press
is lower.
Safar ME. Curr Opin Nephrol Hypertens 2001, 10:257-261
Syst. BP and CV risk in older people
in comparison with younger people
65 – 94 years 35 – 64 years
Prevalence of Hypertension by age in
general population of the U.S.
1988-1991.
Age Percentage (%)
18 – 29 4
30 – 39 11
40 – 49 21
50 – 59 44
60 – 69 54
70 – 79 64
80 65
Swales JD. 1994.
Prevalence of Hypertension
increase with advancing age
70
prevalence of hypertension (%)
40 44
30
20 21
10 4 11
0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+
*P < 0.01.
†
Myocardial infarction only.
Hansson L. Cardiovasc Drugs Ther. 2001;15:275-279.
Benefits of Lowering Isolated
Systolic Hypertension in Patients
≥ 60 Years
Results (% Reduction) Syst-Eur Syst-China
(N = 4695) (N = 2394)
treatment of elderly
hypertensives prevents
more events than similar
treatment in younger
patients.
How to control ??
JNC-7 ( 2003 )
Elderly population has the lowest rates of
BP control.
Not in goal BP
( < 140/90 mmHg or < 130/90 mmHg for those
with DIABETES or CHRONIC KIDNEY DISEASE )
Hypertension Hypertension
Without With
Compelling indication Compelling Indication
JAMA. 2003;289
Lifestyle Modifications to
Prevent and Manage Hypertension
• Reduce weight • Moderate consumption of:
• alcohol
• Increase • sodium
physical • saturated fat
• cholesterol
activity
Alcohol moderation
Exercise
Smoking cessation
Decrease salt intake
Decrease weight
Increase fruit / vegetables intake
JNC-7 Hypertension
Without
Compelling indication
JAMA. 2003;289
JNC-7
Not at goal BP
JAMA. 2003;289
Goals of treatment
JNC-7 (2003) : @ < 140 / 90 mmHg
or < 130 / 80 mmHg for those
with Diabetes or Chronic Kidney
disease.
@ Achieve SBP goal especially in
persons >50 years of age.
EUROPEAN SOCIETY of HYPERTENSION ( 2003 )
: @ At least below 140 / 90 mmHg
(lower values if tolerated)
@ Below 130 / 80 mmHg in Diabetics.
@ Keeping in mind, however, that
systolic below 140 mmHg may be
difficult to achieved in elderly
Guidelines for Drug Therapy in
Hypertensive Elderly
art with small dose, usualy half of adult dose.
Attemp to reduce blood pressure slowly, perhaps by no more than
10 mmHg per month, to allow for autoregulation to maintain
perfusion to vital organ.
Bringing the systolic blood pressure to near 140 mmHg while
insuring that the diastolic pressure is not lowered much below
70 mmHg.
Anticipate side effect and monitor them by questioning and
appropriate laboratory test.
Home of the blood pressure should be encouraged to ensure that
treatment is adequate but not excessive.
Kaplan NM. Circulation 2000 ; 102 : 1079-1081.
Tjoa HI, Kaplan NM. JAMA 1990 ; 164 : 1015-1018.
Choice of Antihypertensive
Therapy for the Elderly (1)
Calcium Antagonists Angina Peripheral vascular disease Heart blockb Congestive heart failurec
Elderly patients
Systolic hypertension
n P
Placebo 66 NS
Diuretics 65 0,0005
n ± SEM.
paired t test with placebo with Bonferoni correction.
ere two p values are given the second is without the correction.
organ TO. Am J Hypertens 2001 ; 14 : 241-247.
organ TO. Am J Hypertens 2001 ; 14 : 241-247.
New Approach in The Treatment of
Isolated Systolic Hypertension
Antihypertensive drugs which reduce systolic blood pressure
more markedly than diastolic blood pressure :
• Aldosterone
antagonist :
Spironolactone
Eplerenone
• Long acting nitrate
• Vasopeptidase
an Zwieten PA. Nephrol Dial Transplant 2001 ; 16 : 1095-1097.
inhibitors
The elderly use more drugs because illness
is more common in older persons,
especially arthritis, cardiovascular and
gastrointestinal disorders, and bladder
dysfunction
Pseudohypertension
Office hypertension (white coat hypertension)
Orthostatic hypotension
14 R