HYPERTENSION IN THE ELDERLY

Hasyim Kasim
Prof DR.Dr.Syakib Bakri
 ELDERLY

> 65 YEARS
BLOOD PRESSURE CLASSIFICATION

JNC 6 – 1997 JNC 7 - 2003

 Physical
Examination
Accurate measurement of blood pressure
General appearance : distribution of body fat, skin lesions,
muscle strength, alertness
Funduscopy
Neck : palpation and auscultation of carotids, thyroid
Heart : size, rhythm, sounds
Lungs : rhonchi, rales
Abdomen : renal masses, bruits over aorta or renal arteries,
femoral pulses, waist circumference
Extremities : peripheral pulses, edema
Neurologic assessment, including cognitive function
 Blood Pressure Measurement

• Patients should be seated with back supported and arm bared and
supported.

• Patients should refrain from smoking or ingesting caffeine for 30

minutes prior to measurement.

• Measurement should begin after at least 5 minutes of rest.

• Appropriate cuff size and calibrated equipment should be used.

• Both SBP and DBP should be recorded.

• Two or more readings should be averaged.

POPULATION : Notice the increase in the
elderly population as the baby – boomers age
PERCENT ELDERLY BY AGE 2000 – 2030
IN AMERICA ( U.S. CENCUS 2000 )

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

• Net effect: Marked reduction in CV

reserve
Systolic BP rises continuously with age
Diastolic BP rises continuously until age 60-70
years
It falls thereafter as a consequence of increased
arterial stiffness

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

Blood Pressure (mm Hg)

With age, SBP increases, 160 SBP
while DBP tends to decline
140
– SBP increases in linear fashion
120
– DBP rises less steeply, plateaus, and declines
slightly after the seventh decade 100
80 DBP

60

15–24 25–34 35–44 45–54 55–64 65–74 75–84

85–99
Age Group (y)

Galarza CR et al. Hypertension. 1997;30:809-816.

 Pathophysiologic changes associated
with hypertension in the elderly (1)
Hemodynamic alterations
Increased peripheral vascular resistance
Decreased cardiac output
Decreased heart rate
Changes in cardiovascular structure and
function
Decrease in vascular compliance
Increase in media-lumen ratio
Decreased myocardial contractility
Left ventricular hypertrophy
Diastolic dysfunction
 Pathophysiologic changes associated
with hypertension in the elderly (2)
Impairment of renal function
Decreased renal perfusion
Reduced glomerular filtration rate

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

ormal systolic blood pressure for older person

was “100 plus the person’s age”.
Isolated Systolic Hypertension : wide
pulse
pressure hypertension
associated with normal or low DBP
Development of aortic pressure abnormalities due to
age-related aortic stiffening

Smulyan H, Safar ME. Ann Intern Med. 2000;132:230.

 SBP-Associated Risks: MRFIT
SBP versus DBP in Risk of CHD Mortality
80.6

48.3

CHD Death Rate 37.4

43.8
34.7
31.
0 38.1
25.5
23.8
24.6
25.3
25.2
20.6 16.9
2 4 .9
13.
9
10.3 12.8
11. 8 12.6
100+ 11. 8 160+
8.8
90–99 8.5 140–159
80–89 9.2
75–79 120–139 Systolic BP
DiastolicBP 70–74
<70 <120 (mm Hg)
(mm Hg)

Neaton JD et al. Arch Intern Med.

1992;152:56-64.
 Relationship between cardiovascular risk and
systolic blood pressure

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 (%)

SBP > 140 mm Hg 65

60 64
DBP > 90 mm Hg
50 54

40 44

30
20 21
10 4 11
0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 The New Guidelines : Classification
WHO-ISH, ESH-ESC, BP BP JNC VII
BSH BP Classification Bp Classification
Optimal <120 / <80 <120/<80 Normal

Normal 120-129 / 80-84 120-129 /80-84 Prehypertension

High normal 130-139 / 85-89 130-139 / 85-89

Grade 1 Hypertension 140-159 / 90-99 140-159 / 90-99 Stage 1

(mild) Hypertension
Grade 2 Hypertension 160-179 /100-109 >160 / >100 Stage 2
(moderate) Hypertension

Grade 3 Hypertension > 180 / >110

(severe)
Isolated Systolic > 140 < 90 Isolated Systolic
Hypertension Hypertension
 Blood Pressure Classification
( JNC-7, 2003 )
BP SBP DBP
Classification mmHg mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

Hypertension
Stage 2 >160 or >100
Hypertension
JAMA. 2003;289
 Distribution of Hypertension Categories
by Age and Sex
IDH Combined Stage 2 ISH Stage 1 ISH
MEN WOMEN
100 100
90 90
80 80
70 70
60 60
% %5 0
50
40 40
30 30
20 20
10 10
0 0
30-39 50-59 70-79 30-39 50-59 70-79
40-49 60-69 80-89 40-49 60-69 80-89
Age Age
Sagie,Larson, Levie : N Engl J Med 1993; 329.
 Benefits of Lowering BP in the
Elderly
SHEP STOP-1 (N MRC
(N = 4736) = 1627) (N =
2394)
BP Reduction (mm Hg) 12/4 20/8 12/5
Results (% reduction)
Total mortality 13 43* 3
All stroke 37* 47* 25*
CHD 25* 13† 19
All CV events 32* 40* 17*

*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)

All CV endpoints 31* 37†

Stroke 42* 38†
All cardiac endpoints – 37‡

*P < 0.003; †P ≤ 0.01; ‡P = 0.09.

Liu L et al. J Hypertens. 1998;16:1823-1829.
Staessen JA et al. Lancet. 1997;350:757-764.
 Characteristics of Hypertension in
the Elderly
• Increased arterial stiffness
• Altered renal function
• Frequent diabetes and hyperlipidemia
• Frequent association with CV disease and heart
failure
• Frequent occurrence with other complications and
disease states (polypharmacy,
noncompliance are common issues)
Because elderly patients are at much
higher risk of cardiovascular disease
than younger patients with mild
hypertension,

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.

Treatment, including those who with

isolated systolic HTN, should follow same
principles outlined for general care of HTN.

Lower initial drug doses may be

indicated to avoid symptoms; standard
doses and multiple drugs will be needed
to reach BP targets. JAMA. 2003;289
JNC-7 Lifestyle modification

Not in goal BP
( < 140/90 mmHg or < 130/90 mmHg for those
with DIABETES or CHRONIC KIDNEY DISEASE )

Initial Drug Choice

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

• Maintain adequate intake of

dietary:
• Avoid • potassium
tobacco • calcium
• magnesium

JNC -7. JAMA, 2003

LIFESTYLE MODIFICATION

Alcohol moderation
Exercise
Smoking cessation
Decrease salt intake
Decrease weight
Increase fruit / vegetables intake
JNC-7 Hypertension
Without
Compelling indication

Stage 1 Hypertension Stage 2 Hypertension

Syst. 140 – 159 OR Syst. > 160 mmHg OR
Diast. 80 – 90 mmHg Diast > 100 mmHg

Thiazide type diuretics 2 Drug Combination

for most for most
May consider ACE inh, Usualy thiazide type with
ARB, CCB, Betablocker ACE inh. or ARB or Beta
Or Combination Blocker or CCB

JAMA. 2003;289
JNC-7

Not at goal BP

Optimize dosage or add additional drugs

Until goal BP is achieved

Consider Consultation with Hypertension Specialist

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)

Keep the number of drugs used to a minimum

Prescribe drugs with a simple, once daily dose
regimen
Avoid drugs which have an adverse effect on:
Brain function
Bladder function
 Choice of Antihypertensive
Therapy for the Elderly (2)
• Choose drugs which:
1. Do not adversely affect
a. Coexisting disease
b. Other drugs which are currently being taken
2. Are not adversely affected by
a. Coexisting disease
b. Other drugs
 Classes of
Antihypertensive Drugs
• ACE inhibitors
• Angiotensin II receptor blockers
• Beta-blockers
• Calcium antagonists
• Central Sympatolitic
• Direct vasodilators
• Diuretics
 Table 4 Guidelines for Selecting Drug Treatment of Hypertension
Class of Drug Compelling Indications Possible Indications Compelling Possible
Contraindications Contraindications

Diuretics Heart failure Diabetes Gout Dyslipidaemia

Elderly patients Sexually active males
Systolic hypertension

Beta-Blockers Angina Heart failure Asthma and chronic Dyslipidaemia

After myocardial infarct Pregnancy obstructive pulmonary Athletes and physically
Tachyarrhythmias Diabetes disease active patients
Heart blocka Peripheral vascular disease

ACE Inhibitors Heart failure Pregnancy

Left ventricular dysfunction Hyperkalaemia Bilateral renal artery stenosis
After myocardial infarct
Diabetic nephropathy

Calcium Antagonists Angina Peripheral vascular disease Heart blockb Congestive heart failurec
Elderly patients
Systolic hypertension

Alpha-Blockers Prostatic hypertrophy Glucose intolerance Orthostatic hypotension

Dyslipidaemia

Angiotensin II Antagonists ACE Inhibitor cough Heart failure Pregnancy

Bilateral renal artery stenosis
Hyperkalaemia
a
Grade 2 or 3 atrioventricular block
b
Grade 2 or 3 atrioventricular block with verapamil or diltiazem
c
Verapamil or diltiazem
ACE inhibitors, Beta blockers, Calcium blockres &
diuretic for the control of systolic Hypertension.

n P
Placebo 66 NS

ACE inhibitors 62 0,005

Beta blockers 46 NS
Calcium blockers 65 0,0005

Diuretics 65 0,0005

Morgan TO, et al. Am.J.Hypertens. 2001 ; 14 : 241 - 247

 Systolic and diastolic blood pressure and pulse rate
achieved with each class of drug

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

The high cost of medication is frequently

an economic burden on elderly persons
living on a fixed income
Studies have shown that persons over
age 65 use 2 to 6 prescription drugs and 1
to 3.4 over-the-counter medicines

The term polypharmacy means "many

drugs" and is used to indicate the use of
more medication than is clinically
indicated or warranted
Problema in the measurements of blood
pressure in the elderly

Pseudohypertension
Office hypertension (white coat hypertension)
Orthostatic hypotension
14 R