The Art of Blood Pressure Management in the Elderly

Dr. Sheri-Lynn KaneSt. Joseph’s Health Centre,Guelph

Geriatrician

Assistant Clinical Professor McMaster University

Overview

Why do we treat hypertension? Why not just apply the evidence to

everyone? Special considerations in the elderly

The Oldest-Old Boomsource: Stats Can 2002

Physiological Changes with Aging

Increased vessel stiffness decrease arterial compliance

Decreased baroreceptor sensitivity Δ in β vasodilatation / α vasoconstriction

balance favours vasoconstriction ability to handle salt

Changes with Aging

Results in high prevalence of both – Combined hypertension > 140/90– Isolated systolic hypertension >160 DBP <95

End Organ Morbidity Cardiovascular

– MI– CHF – diastolic and systolic– PVD

Cerebrovascular– Dementia & Mild cognitive impairment– Stroke – hem and non-hem

Ocular disease Renal failure

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

So why not just aim for target BP’s in everyone?

Evidence to date in those ≥ 85 variable Many prospective, longitudinal studies

show mortality with “normal” or low BP’s ≥ 85 years

Those ≥ 85 yrs represents highly variable population generalizability

Special considerations of BP in elderly

Who: ≥ 80 yr with SBP ≥ 160 DBP≤ 110 mmHg

Eastern Europe, China

Not: accelerated HTN, CHF, dementia, nursing care, ↕ potassium, Cr > 150,

gout

What: DBPC, randomized, ITT

Indapamide SR 1.5mg ± perindopril 2 or 4

target STANDING SBP <150 DBP<80 mmHg

Outcome: fatal or nonfatal stroke

death all cause, CV death, death CHF

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

Special considerations

87yo ♀ lives alone

3 falls in the last 6 months, pelvic F#

HTN since 70’s, difficult to control

No previous MI/stroke/TIA/CHF

LVH by voltage ECG

Meds:Eltroxin 0.15mg

ECASA 325 mg

Ezetrol 10 mg od

Crestor 10 mg od

Pindolol 5 mg od

HCTZ 25 od

Orthostatic Hypotension

Definition: of 20/10mmHg SBP/DBP from

supine to standing at 2 minutes Prevalence

20% > 65 yrs community30% >75 yrs community50% in frail ±institution

Assoc with post-priandial hypotension

Orthostatic Hypotension

? Autonomic or non-autonomic ?Symptomatic or asymptomatic Consequences

– Falls / fractures– Syncope– TIA– MI– Frailty /weight loss mortality

87yo ♀ lives alone3 falls in the last 6 months, pelvic F# HTN since 70’s, difficult to controlNo previous MI/stroke/TIA/CHFLVH by voltage ECGMeds:

Eltroxin 0.15mgECASA 325 mgEzetrol 10 mgCrestor Pindolol 5 mg odHCTZ 25 od

Special considerations80 yo♀ lives aloneLongstanding refractory hypertensionMeds:

Altace 10mg odNorvasc 5 mg bid - to bid 3 months agoHCTZ 25mg od

BP 188/88 both arms in any position, light headed with standing

“Feels awful”, multiple falls, losing weight

Pseudohypertension

Defn: Artificial elevation of BP when measured

by indirect cuff vs intra-arterial Often associated with some hypertension Due to stiff calcified vessels

What to do?80 yo♀ lives aloneLongstanding refractory hypertensionMeds:

Altace 10mg odNorvasc 5 mg bid - to bid 3 months agoHCTZ 25mg od

BP 188/88 both arms in any position, light headed with standing

“Feels awful”, multiple falls, losing weight

Loss of diurnal variations

~ 20% HTN are non-dippers > 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

Summary Need orthostatic BP’s 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