Practical Approach to the Management of Hypertension in the Elderly

Shakaib U. Rehman, MD, Florence N. Hutchison, MD, and Jan N. Basile, MD, Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston

Published Online: October 15, 2007 - 11:55:08 AM (CDT)

Hypertension is the most common diagnosis made in the elderly. A 55-year-old person has a 90% likelihood of developing hypertension in his or her lifetime. Uncontrolled hypertension increases cardiovascular and renal morbidity and mortality. Reducing high blood pressure decreases the risk for cardiac, cerebral, and renal events, as well as for death. Although effective treatments are available, control rates in the elderly have been grim, with only 1 in 5 older adults with hypertension controlled to goal, mostly because of failure to reduce systolic blood pressure. Weight loss, reduced salt intake, and regular exercise can effectively prevent and treat hypertension. Despite concerns about adverse effects in the elderly, many classes of antihypertensive agents can be used safely as first-line treatment, including thiazide-type diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers. Beta-blockers are usually reserved for those with a compelling indication. Since it usually takes 2 or more medications to achieve goal blood pressure in the elderly, the use of fixed-dose combination medications may be cost-effective, as well as improve adherence.

Persons aged 65 years and older comprise one of the most rapidly growing segments of the US population, and 65% of people in this age-group have hypertension,¹ defined as a systolic blood pressure (BP) ≥140 mm Hg and/or a diastolic BP ≥90 mm Hg.

The incidence of hypertension increases with age. Individuals who are normotensive at age 55 have a 90% lifetime risk for developing hypertension.² Isolated systolic hypertension is the most common form of hypertension in the elderly. Isolated systolic hypertension is defined as a systolic BP ≥140 mm Hg and a diastolic BP >90 mm Hg. In older adults with hypertension, systolic BP is a stronger predictor of cardiovascular risk than diastolic BP. This is the result of age-related stiffening of the larger arteries, particularly the aorta. Diastolic BP, in contrast, remains normal or decreases after the age of 55 years, resulting in a widening of the pulse pressure (the difference between systolic and diastolic BP).^3,4

Hypertension is an independent risk factor for cardiovascular disease (CVD), heart failure, stroke, renal failure, dementia, and death.⁵ The relationship between cardiovascular (CV) events and hypertension is continuous and linear: the higher the BP, the greater the risk. Each incremental increase of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP doubles the risk of CVD across the entire BP range, from 115/75 mm Hg to 185/115 mm Hg.⁴ Reducing elevated BP with lifestyle modification and antihypertensive therapy has been associated with a 50% lower risk of heart failure, a 35% to 40% reduced risk of stroke, and a 25% reduced risk of myocardial infarction.⁶ Many studies have shown that antihypertensive treatment in elderly patients may decrease the likelihood of developing cognitive impairment or slow its progression.^7,8 Even in hypertensive patients older than 80 years, antihypertensive therapy significantly reduces the incidence of stroke and of fatal and nonfatal CV events.^9,10

Despite the known beneficial effects of BP reduction, control rates remain lowest among the elderly. Compared with the general population, in which the control rates are 31%, only 27% of elderly hypertensive patients have their BP controlled to the goal of 140/90 mm Hg or less.¹¹ It is noteworthy that virtually all this uncontrolled hypertension can be attributed to the difficulty of controlling systolic BP in older adults.¹²

Evaluation

The diagnosis of hypertension is established in elderly persons when the BP measurement is ≥140/90 mm Hg on at least 2 separate office visits. The use of an appropriate-sized cuff is very important; a too-small cuff may erroneously record a higher BP. Orthostatic changes in BP must be assessed. BP should be measured in the supine, sitting, and standing positions on the first visit and anytime the patient complains of lightheadedness or dizziness while on therapy.

The purpose of the clinical evaluation of elderly hypertensive patients is to identify risk factors for CVD as in all patients (Table 1), assess the presence of comorbidities, and define the current stage of hypertension.

There are 2 stages of hypertension.¹³ Stage 1 describes a systolic BP of 140 to 159 mm Hg and/or diastolic BP of 90 to 99 mm Hg. Stage 2 is defined by a systolic BP of ≥160 mm Hg and/or diastolic BP of ≥100 mm Hg.

Since many older adults may be taking medications for other conditions, a medication review is important to avoid drug?drug interactions. Moreover, certain medications can cause elevations in BP (Table 2), such as nonsteroidal antiinflammatory drugs, decongestants, corticosteroids, oral contraceptives, and ephedrine-containing supplements.

Assessment of risk factors includes evaluation for diabetes mellitus, lipid disorders, chronic kidney disease (CKD), and smoking history, as well as family history of premature CVD. Target-organ damage assessment includes a thorough history and physical examination to determine the presence of retinopathy and carotid or abdominal bruits (Table 3). BP should be measured in both arms, as subclavian artery stenosis may produce a false-low BP. Some elderly patients may present with pseudohypertension, a phenomenon in which the brachial artery is calcified and hardened and cannot be compressed by the BP cuff, resulting in false-high systolic BP recordings. Pseudohypertension should be suspected in an older adult with elevated BP who is using antihypertensive therapy, when no evidence of target-organ damage is apparent or in the presence of hypotensive symptoms.

Intraarterial BP measurement can confirm or rule out pseudohypertension. An electrocardiogram (ECG) should be obtained to assess for the presence of left ventricular hypertrophy. Basic laboratory tests include a urinalysis, complete blood cell count, basic metabolic panel, and a fasting lipid profile. The routine measurement of microalbuminuria in the nondiabetic patient remains controversial.

An extensive evaluation for identifiable secondary causes of hypertension is not warranted in most individuals, except in those who present with very high BP for the first time, a worsening of previously well-controlled hypertension, or other clinical symptoms or signs suggestive of secondary hypertension, such as vascular bruits, symptoms of catecholamine excess, or unprovoked hypokalemia.

Secondary hypertension has an identifiable cause, whereas primary hypertension has no known cause (ie, idiopathic). Common causes of secondary hypertension in the elderly include renal artery stenosis causing renovascular hypertension, CKD, sleep apnea, and hyperthyroidism or hypothyroidism (Table 4).

Treatment Goal

The treatment of hypertension has been shown to reduce CV and renal morbidity and mortality. The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends a BP goal of <140/90 mm Hg, regardless of age or the presence of isolated systolic hypertension. For high-risk hypertensive patients with comorbid diabetes or CKD, the goal is <130/80 mm Hg (Table 5).¹³ The primary aim should be to achieve the systolic BP goal, as most patients, including the elderly, will achieve the diastolic BP goal if the systolic BP is controlled. In clinical trials involving the elderly, reducing diastolic BP to <55 mm Hg did not improve outcomes, so diastolic BP should not be reduced below this level.¹⁴

Treatment

Lifestyle modification
Lifestyle modification is an effective strategy for prevention, as well as for treatment, of hypertension and should be recommended in all patients (Table 6).¹³ Moreover, lifestyle modifications, such as weight loss and sodium restriction, may decrease the need for antihypertensive medications and minimize associated CV risk factors in the elderly. Smokers should be encouraged and assisted to quit smoking for overall CVD risk reduction. Heavy alcohol use should be discouraged, since it can worsen BP control.

Drug therapy
The effectiveness of first-line antihypertensive therapy has been demonstrated in several prospective clinical trials involving elderly patients with combined systolic/diastolic hypertension (Table 7). These studies indicate that a variety of antihypertensive agents are equally successful in reducing the risk of CVD and stroke in elderly hypertensives, including those with diabetes.^10,15 CV outcomes have been shown to be related to the achieved BP reduction; thus, the choice of initial agent may not be as important as the reduction in BP achieved.^10,15 Although the first priority in the treatment of hypertension is the control of BP, the specific antihypertensive agent used should be chosen according to the presence of a coexisting compelling indication. Those compelling indications requiring the use of specific antihypertensive drugs as initial therapy are listed in Table 8. The classes of antihypertensive medications listed as supplemental agents in Table 9 should not be used as primary therapy, because of insufficient outcome-based data about their impact on mortality and morbidity. These agents can, however, be used as supplementary therapy if the first-line agents do not help the patient to achieve goal BP.

The US Food and Drug Administration recently approved the new antihypertensive drug aliskiren (Tekturna), a direct renin inhibitor. Aliskiren is an effective antihypertensive agent that is administered once daily and is associated with dose-dependent systolic and diastolic BP reductions.¹⁶ There is currently no evidence that it has a greater benefit than the first-line agents. It can be used as an initial monotherapy in the elderly or as an add-on therapy to a thiazide-type diuretic or an angiotensin receptor blocker (ARB). It has not been well-studied with a beta-blocker or an angiotensin-converting-enzyme (ACE) inhibitor. Aliskiren is not indicated for use in patients with a compelling indication.

Diuretics. JNC 7 recommends that a thiazide-type diuretic should be used as initial therapy for most patients with hypertension, regardless of age. ACE inhibitors, ARBs, and calcium channel blockers have demonstrated similar efficacy in randomized, controlled outcome trials. The role of beta-blockers as initial antihypertensive monotherapy in the elderly without a compelling indication remains unclear. A thiazide-type diuretic and a calcium channel blocker of the dihydropyridine type are the only 2 classes of antihypertensive medications shown to decrease mortality and morbidity in elderly persons with isolated systolic hypertension.^17-19 In a substudy of the Losartan Intervention for Endpoint Reduction (LIFE) trial, initial therapy with the ARB losartan potassium (Cozaar) was shown to reduce CVD mortality and morbidity more than initial therapy with the beta-blocker atenolol (Tenormin) in elderly persons with isolated systolic hypertension and ECG evidence of left ventricular hypertrophy.²⁰ Alpha₁-blockers should not be used as initial monotherapy,²¹ but they can be used as add-on therapy in the elderly.

Since thiazide-type diuretics can cause gout and hypokalemia, physicians should use alternative agents in patients prone to these conditions. Although the incidence of new-onset diabetes mellitus may be greater in patients treated with a thiazide-type diuretic compared with an ACE inhibitor or a calcium channel blocker,²¹ this increase in new-onset diabetes has not been associated with an increase in CV events.¹⁸

Other considerations affecting the choice of antihypertensive therapy include drug tolerability, cost, and compatibility with other medications.

If a drug is not tolerated or is contraindicated, then an agent from another class proven to reduce CV events should be used.

Initial dose. As elderly patients often have reduced renal and hepatic drug metabolism, many physicians believe that the usual dose of the initial antihypertensive agent in the elderly should be half of that used in younger patients. However, this approach is not evidence-based and often leads to underdosing and inadequate BP control. The full initial dose should be titrated slowly until the BP goal has been achieved at the dose with the fewest side effects.

Combination therapy. Most elderly patients with hypertension will require 2 or more medications to control their BP. The use of low-dose, fixed-dose combination therapy may not only enhance BP reduction but also reduce the risks of side effects compared with higher-dose, single-agent therapy.¹³ JNC 7 recommends starting combination therapy when systolic BP is ≥20 mm Hg and diastolic BP is ≥10 mm Hg above goal (the "20/10 rule").¹³

Most experts agree that a low-dose, thiazide-type diuretic should be part of the fixed-dose combination therapy, unless contraindicated, because of the efficacy in BP reduction, additive effects with other classes of antihypertensive medications, minimal side effects, and low cost.

Patient involvement. Involving patients in goal setting, encouraging home BP monitoring, and incorporating their cultural beliefs, such as misconceptions about drugs, and previous experiences with antihypertensive medications into the treatment plan will improve adherence with antihypertensive regimens and thus improve the chances of BP control.¹³

Monitor Treatment

The management of elderly patients with hypertension is summarized in the Figure. The follow-up of hypertensive patients depends on the severity of the BP elevation and the presence of comorbid conditions. Patients should be followed up at least monthly until their BP is controlled. Those with stage 2 hypertension or with additional comorbid conditions require more frequent follow-up. Once BP is controlled, the patient should be seen every 3 to 6 months.¹³ Patients should always have access to their physician. It is useful to write the BP goal on the patient's prescription bottle. Regardless of the reason, if the patient stops taking an antihypertensive medication, she should promptly call the physician's office to discuss it.

Figure—Management of elderly patients with hypertension.

Historically, all clinical decisions are based on seated BP, both to diagnose and to evaluate the response of BP to therapy. Because elderly individuals are prone to postural hypotension and falls, standing BP should be measured, preferably at every visit.²² Many physicians make a therapeutic decision on the basis of office sitting BP, but instead the decision should be based on the standing BP, to avoid postural hypotension in those most prone to this condition.

Home BP monitoring in the elderly should be encouraged; it has been shown to improve therapeutic adherence²³ and to be a better predictor of future CV events than office BP readings.²⁴ Home BP values used for the diagnosis and treatment of hypertension are different than office values. Home BP readings >135/85 mm Hg are generally regarded as hypertension.¹³ It is also advised that home measurement devices be checked regularly for accuracy because of the lack of standardization for many of these devices. Ambulatory BP monitoring is now available and is recommended for the evaluation of "white-coat" hypertension. Ambulatory monitoring also provides information on the overall BP load and the extent of BP reduction during sleep. In most individuals, BP decreases by 10% to 20% during the night; those in whom such reductions are not present ("nondippers") are at increased risk for CV events.^25,26

Conclusion

Hypertension is the most common diagnosis in elderly individuals. The association of BP elevation with vascular risk is linear, continuous, and independent of other risk factors. Treatment of hypertension reduces CV events, stroke, and progression of CKD in elderly persons, including those 80 years of age and older. Isolated systolic hypertension remains the most common and most difficult-to-treat form of hypertension in the elderly.

Patients should be counseled on lifestyle modifications, such as weight loss and salt restriction. When antihypertensive therapy is indicated, BP should be followed more closely than in younger patients, with special attention to postural BP changes. A thiazide-type diuretic should be used as initial therapy, unless a compelling indication for another agent is present. Most classes of antihypertensive agents are safe and effective and can be used as initial monotherapy or in combination with thiazide-type diuretics. In patients with isolated systolic hypertension, initial treatment with a thiazide-type diuretic or a dihydropyridine calcium channel blocker has been shown to decrease morbidity and mortality. Specific classes of antihypertensive agents should be chosen when compelling indications are present. It is important to remember that most patients will require more than 1 agent to get to goal BP. It is advisable not to lower diastolic BP below 55 mm Hg.

Disclosure statement
Dr Basile receives grant/research support from the NHLBI, Boehringer Ingelheim, and Novartis. He is on the Speaker's Bureau of Abbott, AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Forest, GlaxoSmithKline, Merck, Novartis, and Pfizer. Drs Rheman and Hutchison have nothing to disclose.

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This work was supported in part by the Department of Veteran Affairs Research Service.

SELF-ASSESSMENT TEST

1. Which statement about hypertension in the elderly is not true?

1. It is the second most common diagnosis, after coronary heart disease
2. A 55-year-old has a 90% chance of developing hypertension
3. Systolic BP is a stronger predictor of CV risk than diastolic BP
4. Isolated systolic hypertension is the most common form of hypertension in older adults

2. Which agent is not associated with elevations in BP?

1. Cyclosporine
2. Ibuprofen
3. Celecoxib
4. Clarithromycin

3. All of these drug classes have been shown to improve outcomes in older adults with hypertension except:

1. ACE inhibitors
2. Alpha₁-blockers
3. ARBs
4. Calcium channel blockers

4. Which agent would be least appropriate in an older adult with hypertension and diabetes?

1. Losartan
2. Chlorothiazide
3. Aliskiren
4. Captopril

5. Which statement about treatment monitoring is not true?

1. Patients with stage 2 hypertension should be seen once a month until BP is controlled
2. After BP is controlled, patients should be followed up every 3 to 6 months
3. Home BP measurements >135/85 mm Hg qualify as hypertension
4. Therapeutic decisions should be based on sitting and standing BP in the elderly

(Answers at end of references list)

References

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4. Lewington S, Clarke R, Quizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913.
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11. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003;290:199-206.
12. Franklin SS, Jacobs MJ, Wong ND, et al. Predominance of isolated systolic hypertension among middle-aged and elderly USA hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES III). Hypertension. 2001;37:869-874.
13. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report. JAMA. 2003;289:2560-2572.
14. Somes GW, Pahor M, Schorr RI, et al. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med. 1999;159:2004-2009.
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17. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255-3264.
18. Kostis JB, Wilson AC, Freudenberger AS, et al. Long-term effect of diuretic-based therapy on fatal outcomes in subjects with isolated systolic hypertension with and without diabetes. Am J Cardiol. 2005;95:29-35.
19. Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet. 2001;355:865-872.
20. Kjeldsen SE, Dahlof B, Devereux RB, et al. Effects of losartan on cardiovascular morbidity and mortality in patients with isolated systolic hypertension and left ventricular hypertrophy: a Losartan Intervention for Endpoint Reduction (LIFE) substudy. JAMA. 2002;288:1491-1498.
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Answers: 1. A; 2. D; 3. B; 4. C; 5. A.