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09 February 2010

Hypertension in the elderly

Elderly patients, if treated for their high blood pressure, have fewer heart attacks, strokes and congestive heart failure, than the same age group with untreated hypertension.

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Elderly patients, who are treated for their high blood pressure, have fewer heart attacks, strokes and congestive heart failure, than the same age group with untreated hypertension.

The benefits of treatment

Research also reveals that the benefits of treating hypertension are even greater for older patients than they are for younger hypertensives.  This is probably because the risk for cardiovascular disease increases with age.

The numbers change

Although reaching the age of 50 is certainly not seen as old, the significance of the blood pressure readings may start to change.  The systolic blood pressure, the top number, is watched closely. For those under 50 years of age, the systolic and diastolic numbers are of equal importance. A raised pulse pressure is also a good predictor of cardiovascular events.  Pulse pressure is the difference between the systolic and diastolic number.

Isolated Systolic Hypertension (ISH)

ISH is a condition found in elderly patients and is due to age-related stiffening of the arteries.  It is diagnosed when the systolic blood pressure is consistently above 160 mm Hg (high), and the diastolic below 90 mm Hg, (within normal limits).  ISH is associated with increased stroke and heart problems, and should be treated.

White coat hypertension

This condition is suprisingly common in older people, and must be distinguished from isolated systolic hypertension.  In this case, blood pressure readings are only elevated if taken by a doctor, and normal elsewhere.  24-hour monitoring is sometimes required to confirm the diagnosis.

Postural Hypotension

Hypertension therapy in the elderly starts with lifestyle modification.  If goal blood pressure cannot be achieved, pharmacological treatment is indicated.  Some patients may experience a drop in pressure when changing position.  Therefore, when monitoring older patients, the blood pressure should be repeated after standing for two minutes.

Essential Hypertension

Most elderly patients have essential or primary hypertension, for which they may have been treated since a younger age.  Sometimes it is only diagnosed at an older age.  Essential hypertension has no obvious cause, but genetic and environmental factors play a role.  The same risk factors and lifestyle modification are applicable to all age groups.

Lifestyle changes

The seemingly inevitable elevation in blood pressure with age is much more pronounced in our Western society.  It is a reflection of lifestyle and diet.  Changing lifestyle habits are crucial to the elderly hypertensive.  A low-salt diet is especially important, as many patients seem to become more sensitive to salt with age.  Increased intake of potassium, the heart friendly mineral, must be emphasized.  Not only is the diet very often potassium deficient, but many diuretics (water tablets) cause loss of this mineral.  Exercise, adapted to ability, must be regular and should include stretching for flexibility.

Risk factors add up

The risk for heart disease and stroke increases with age.  Older patients are more likely to have co-existing disease, like arteriosclerosis, that increases cardiovascular risk.  Arteriosclerosis is when fatty deposits are made in the inner layer of blood vessels.   This can clog it up and obstruct flow.  When this happens in the artery that supplies the kidney, it can cause secondary hypertension.  Arteriosclerosis also increases cardiovascular incidents, like heart attacks and strokes.  Elderly patients with hypertension often already have target organ damage or clinical cardiovascular disease.  All these factors add up to increase total risk.  However, it also increases the benefit of treating the hypertension in these patients.

Secondary prevention

If you have had a stoke or heart attack before, you are at risk for having another. You may have survived the first attack, but when discharged, many of the same risk factors still exist.  A management plan is needed to avert a recurrence.  This is called secondary prevention.  These patients have the highest risk of all, and many are elderly.

Common misconceptions

Many people believe that older patients do not tolerate hypertension therapy, do not benefit from it, and comply poorly.  Research shows the response and compliance to be at least as well as the younger group.  The benefit, however, is much higher in the older group.

Go slow

In older patients with raised blood pressure, the aim will be to lower the pressure gradually over a period of six months. Lifestyle and diet modification is the first line of therapy.  If drugs are needed, the type and dosage that cause the least side effects will be used.

(Dr Kathleen Coetzee, MBChB) 

Read more:
Am I at risk for hypertension?
Hypertension and your heart

 
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