Annals of Long Term Care

Point: Treating Hypertension in the Elderly

An 83-year-old woman with a prior myocardial infarction (MI) had a blood pressure in the sitting position of 172/90 mm Hg in the right brachial artery and 174/90 mm Hg in the left brachial artery. Her standing blood pressures were similar. Her physician was uncertain whether he should treat her blood pressure because of differing published opinions,1,2 and because of a debate he had heard at a national meeting moderated by the author in which conflicting opinions were expressed.

Should this woman be treated with antihypertensive drug therapy? The answer is yes,3,4 and this article will discuss why.

Hypertension was present in 57% of 1160 older men (mean age, 80 yr) and in 60% of 2464 older women (mean age, 81 yr) in a nursing home, with two-thirds of these older persons having isolated systolic hypertension.5 Of 1819 older persons (mean age, 80 yr) living in the community and seen in an academic geriatrics practice, 58% had hypertension (37% with isolated systolic hypertension).6 Target organ damage, clinical cardiovascular disease (CVD), or diabetes mellitus was present in 70% of older persons with hypertension.6 The prevalence of hypertension in older persons with diabetes mellitus in a nursing home was 76%.7

The higher the systolic blood pressure (SBP) or diastolic blood pressure (DBP) in older persons, the higher the cardiovascular morbidity and mortality.8 Increased SBP and pulse pressure are stronger risk factors for cardiovascular morbidity and mortality in older patients than is increased DBP.9,10 An increased pulse pressure found in older persons with isolated systolic hypertension indicates decreased vascular compliance in the large arteries and is even a better marker of risk than is SBP or DBP.9,10 The Cardiovascular Health Study found in 5202 older men and women that a brachial SBP higher than 169 mm Hg increased the mortality rate 2.4 times.11

Hypertension in older persons is a major risk factor for coronary events,12-14 stroke,12,15-17 congestive heart failure (CHF),12,18,19 and peripheral arterial disease (PAD).20-23 Older persons are more likely to have hypertension and isolated systolic hypertension, to have target organ damage and clinical CVD, and to develop new cardiovascular events; they are less likely to have hypertension controlled.

Barriers to treatment of hypertension include physicians not understanding that frail elderly patients should be treated according to recommended guidelines to reduce cardiovascular morbidity and mortality. Elderly persons with hypertension, if treated appropriately, will have a greater absolute decrease in such cardiovascular events as major coronary events, stroke, CHF, and renal insufficiency, and a greater reduction in dementia24 than younger persons. Some elderly persons living in the community may not be able to afford their antihypertensive medications.25

Numerous prospective, double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces the development of new coronary events, stroke, and CHF in older persons.26 Therapy with antihypertensive drugs reduces the incidence of all strokes by 38% in women, by 34% in men, by 36% in older persons, and by 34% in persons older than 80 years.16 The overall data suggest that reduction of stroke in older persons with hypertension is related more to a decrease in blood pressure than to the type of antihypertensive drugs used.16

In the Perindopril Protection Against Recurrent Stroke Study,27 perindopril plus indapamide reduced stroke-related dementia by 34% and cognitive decline by 45%. In the Systolic Hypertension in Europe trial,28 nitrendipine decreased dementia by 55% at 3.9-year follow-up.