Open Journal Systems

REVIEW ARTICLES

Received: 15/10/2015

Accepted: 23/11/2015

Systemic arterial hypertension in the elderly. Recommendations for clinical practice

Martín Rosas-Peralta,^a Gabriela Borrayo-Sánchez,^b Alejandra Madrid-Miller,^c Erick Ramírez-Arias,^d Gilberto Pérez-Rodríguez^e

^aDivisión de Investigación en Salud

^bDirección Médica

^cServicio Terapia Posquirúrgica

^dServicio de Urgencias

^eDirección General

Hospital de Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México

Communication with: Martín Rosas-Peralta

Email: mrosas_peralta@hotmail.com

Hypertension is common in people aged 65 and older. In those aged 70 and older, hypertension is more poorly controlled than in those whose age is between 60 and 69 years. The number of trials available concerning the elderly population is limited; therefore, strong recommendations on blood pressure (BP) goals are limited. The American College of Cardiology has recently published a consensus report of management of hypertension in the elderly population. This review presents an overview of that consensus report and reviews specific studies that provide some novel findings regarding BP goals and the progression of nephropathy. In general, the evidence strongly supports a BP goal < 150/80 mm Hg for the elderly with scant data in those aged 80 and older. However, it was decided to set the goal < 140/90 mm Hg, unless the patient cannot tolerate it, and then try to achieve 140-145 mm Hg. Diuretics and calcium antagonists are the most efficient treatment; however, most patients will require two or more drugs to achieve such goals.

Key words: Elderly; Hypertension

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Some common clinical characteristics in elderly patients with hypertension (HT) are that almost 90% have an associated comorbidity, have a greater predisposition to atrial fibrillation, most are sodium-sensitive, and elevated systolic pressure is overwhelming among them. They are generally more sensitive to antihypertensive drugs. In this age group, the sudden drop in blood pressure, even when figures are registered close to 200 mm Hg, should be done with caution, since it is not uncommon for older adults to have atherosclerosis, and in fact reduction to normal levels can show sites of hypoperfusion from chronic angio-occlusion. Therefore, it is highly recommended to lower blood pressure gradually and test renal function. Measuring the carotid intima-media thickness can give more information about the extent of vascular involvement. Diuretics have proven efficacy and safety; however, caution should be exercised with their use as monotherapy, because high doses are not recommended. Calcium antagonists are effective, and in combination with diuretics can allow lower doses, thereby reducing side effects. The latest generation calcium antagonists have a very important role, especially with elderly patients with chronic obstructive pulmonary disease (COPD). The combination of this type of calcium channel blockers with statins should always be considered. The use of antiplatelet drugs, once pressure is controlled and there is no contraindication or risk of bleeding, is fully justified. If there is a carbohydrate metabolism disorder or obesity, ACE inhibitors (ACEI) or angiotensin II receptor blockers (ARB II) should always be seen as first-line. It should be remembered that arteriovenous conduction disorders are relatively common, so drugs that affect chronotropism require close monitoring.

The Sys Eur study found that if diastolic pressure during treatment falls below 70 or 60 mm Hg in patients with isolated systolic hypertension, the prognosis was worse than in those who managed to keep it above 70 mm Hg. There is no consensus on what is the minimum limit of diastolic pressure that can be allowed during the treatment of elderly patients with isolated systolic HT. In subjects over age 79, studies indicate a beneficial effect in terms of morbidity, but so far none has shown a significant increase in survival. The SCOPE study notes that everyone should be treated, as it significantly reduces the risk of cerebral vascular event (CVE), which definitely significantly affects the quality of life and life expectancy. Our group suggests starting with low doses of diuretics and adding low doses of calcium channel blockers or ACE inhibitors. The use of beta-blockers should be reserved at low doses in ischemic patient. 

Another aspect that is often a determining factor in our decision-making is that there is an association between cognitive impairment and systolic pressure. Multi-infarct dementia is common. In fact, many patients who began testing on suspicion of Alzheimers ended up diagnosed with multi-infarct dementia. Echocardiography, metabolic profile, preexisting renal function, chest x-ray, and electrocardiogram are required. Despite increased knowledge regarding cardiovascular risk in hypertensive patients, its diagnosis and especially its treatment with the development of new drugs and combinations that have established specific therapeutic recommendations, poor control of blood pressure (BP) persists, especially in the older population, where the prevalence of hypertension in our country is up to 65% of subjects older than 60 years.

Recent data have confirmed that we are still far from achieving the recommended goals. There are several reasons for this insufficient control. The PRESCAP study collected data from nearly 6,000 hypertensive patients over age 65 seen in primary care. Only 33% were well controlled, which is a figure considerably higher than previous studies, but down to 10% when looking at hypertensive diabetics. As for the patients’ characteristics, the variables that were associated with poor control were the presence of diabetes, alcohol consumption, and smoking, but insufficient medication treatment was also detected (monotherapy was used in more than half), and too much "tolerance" from doctors, who only changed the treatment in 17% of patients who did not reach the intended target (“slight improvement" over previous measurements, whose status changed in only 12% of cases). But hypertension control depends not only on comorbidity and the pharmacological treatment received; there are other factors related to patients’ social networks that are traditionally not given much importance and that appear to exert a real influence, both in knowledge and in treatment and the degree of control of hypertension, especially in hypertensive older adults. In a cross-sectional study of 3483 people over age 60 representative of the Spanish population living at home (not in nursing homes or other institutions), in which the prevalence of hypertension was 68%, only two-thirds of them knew they had high BP, and 85% of these were receiving drug therapy. Although 63% complied with treatment, only 30% of treated hypertensives had controlled BP. An association was found between hypertension and some variables of social integration. The prevalence of hypertension was lower in married or cohabitating individuals, compared with those unmarried or living alone. It was also shown that knowledge of having HT and treatment adherence were higher in hypertensive patients who associated more with family and friends or neighbors.

It is essential to develop strategies that increase the degree of adherence of these patients at high cardiovascular risk. Recently published results from the FAME study (Federal Study of Adherence to Medications in the Elderly) included 200 patients over 65 years taking at least four drugs chronically. In the first two months baseline data were obtained on compliance and BP values ​​and low density lipoprotein (LDL-C). Then a six-month intervention phase began, during which patients were dispensed their medication for each day, while being closely monitored by pharmacy staff and receiving education aimed at better control. At the end of this period, the degree of compliance with treatment had increased from 61.2 to 96.9% and a significant reduction had been achieved in systemic blood pressure (SBP) and LDL-cholesterol. Subsequently, patients were randomly divided into two groups: "normal care," for those who returned to their previous treatment and follow-up, and "intervention group", who continued the pharmaceutical monitoring program. After six months, patients in the first group once again presented an adherence of 69.1% (it remained at 95.5% in the intervention group) and differences were found between the groups in SBP values​​, but not in LDL cholesterol levels. Therefore, we must not forget that to achieve the sometimes very ambitious goals that are necessary for optimal control of cardiovascular risk, especially in older patients, it is not sufficient to indicate pharmacological measures of proven benefit, we must consider other factors such as social integration, degree of compliance, and so on. It is essential to develop programs coordinated with other health and social service professionals that allow us to provide the best medical care to this population group.

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