Hypertension and Cardiovascular Disease in the Elderly

Risk of hypertension increases with age

Hypertension in the Elderly
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Is high blood pressure a normal part of aging?

High blood pressure is more common in older adults compared to younger demographic groups, but it should not be treated as a normal part of aging. Arteries become stiff and less compliant as we age. This results in elevated systolic blood pressures, although diastolic blood pressure generally stabilizes in people between the ages of 50 and 60. The "pulse pressure" is the difference between the systolic and diastolic blood pressure.

The risk of cardiovascular disease increases as the pulse pressure increases. 

Systolic hypertension in the elderly was once used to be known as “isolated systolic hypertension," characterized by a systolic blood pressure greater than 160 mm Hg with a diastolic blood pressure of less than 90 mm Hg. Systolic hypertension is the most common cause of hypertension in patients over the age of 50, which is significant because it is a much greater risk factor for heart disease and stroke compared to other forms of primary hypertension. It is also associated with an increased risk of mortality from cardiovascular events. Although older adults usually have less compliant arteries, experts all agree that it is important to continue to aim for a normal blood pressure in the elderly.

The Importance of Blood Pressure Treatment in the Elderly

There are several factors unique to the elderly or aging population that make blood pressure control especially important:

1. Increased risk of cardiovascular events compared to younger patients who have the same risk factors.

2. Systolic blood pressure is likely to be higher, with isolated systolic hypertension more common in this population.

3. Older patients have a higher incidence of other medical conditions that should be taken into account when choosing the right blood pressure medication.

4. Hypertension affects cognition negatively even in middle-aged adults. There also appears to be a relationship between hypertension and dementia. Many studies have shown that patients treated with antihypertensive medication have a lower risk of development of cognitive impairment, dementia, and atrophy of the brain. Long-term treatment of high blood pressure significantly lowers the risk of both Alzheimer dementia and vascular dementia.

High blood pressure is the most significant risk factor for vascular disease of all types and for death. Many studies have shown that patients with treated high blood pressure had significantly lower numbers of strokes, deaths from stroke, heart attacks, other cardiovascular events, deaths from cardiovascular events, and all-cause mortality. An analysis of the “numbers needed to treat,” which reflects how many people must be treated in order for one person to benefit from treatment, shows that less than one hundred older adults need to be treated for high blood pressure to prevent one individual from experiencing a serious consequence like a stroke or heart attack.

NNT is a measure of the cost/benefit ratio of a treatment. The NNT associated with blood pressure treatment in older adults suggests that blood pressure treatment is particularly cost effective over time, since treatment may prevent many catastrophic events that are costly to treat and may also cause significant loss of independence.

What Should Older People With Hypertension Do to Improve Their Numbers?

Lifestyle modifications lower blood pressure, but it is not clear if they reduce these events. The DASH (Dietary Approaches to Stop Hypertension) diet is effective in decreasing systolic blood pressure in older adults, since it appears they may be more responsive to the effects of sodium (salt) in their diets. Active older adults benefit from cardiovascular exercise and other lifestyle recommendations, including tobacco cessation and moderation of alcohol use, apply to all age groups.

Treatment of blood pressure in older people should take other conditions into consideration:

  • Lowering blood pressure appears to be more important than the use of a particular class of drug.
  • Treatment with antihypertensive medication reduces the risk of worsening high blood pressure by 94 percent.
  • Heart failure, which is often the result of chronic high blood pressure, was shown to be reduced by 42 percent in older patients with high blood pressure treated with medication compared to those who had high blood pressure that as not treated.
  • High blood pressure can cause kidney disease, but a large study showed that lowering blood pressure was more effective than dietary modification in reduction of risk.

What Is a Reasonable Blood Pressure Target for the Elderly?

Although current guidelines for the general population suggest a blood pressure goal of less than 140 mm Hg systolic and a diastolic blood pressure less than 90 mm Hg, the target for elderly patients should be a systolic blood pressure less than 150 mm Hg and diastolic blood pressure less than 90 mm Hg. In elderly patients with diabetes or chronic kidney disease, the goal for blood pressure reduction should be a systolic blood pressure less than 140 mm Hg. Older patients who are otherwise fit and healthy may consider a target for blood pressure below 140 mm Hg.

The treatment goal for blood pressure is reached in only about 70 percent of the elderly who take medications for hypertension, but studies have demonstrated significant benefits with treatment, even when the target blood pressure goal is not achieved. These benefits include reduction of the risk of both hemorrhagic and ischemic strokes is decreased and a 4.4 percent reduction in heart failure.

Should All Elderly People With High Blood Pressure Be Treated With Medication?

Although changes in lifestyle, like weight loss, salt reduction, and exercise, are beneficial, in real life it appears that lifestyle modifications are not always carried out consistently in a way to allow older patients to see benefits. Lifestyle modifications are not always easily made in older adults and can also be expensive, when professional nutrition counselors, exercise therapists, and transportation costs, among other factors, are taken into consideration.

It is important for all patients with high blood pressure to live a healthy lifestyle, but there is no real evidence that these measures have a significant influence on reduction of risk of serious medical sequelae to high blood pressure in the elderly population. Research shows that use of high blood pressure medication is much more effective for reduction of cardiovascular events.

In general, people with significant risk factors for cardiovascular disease, whatever their age, should be treated with a drug to meet their target blood pressure. At one time, there was some acceptance of the idea of stopping treatment for patients who were over the age of 79, but evidence clearly shows that outcomes, including strokes, cardiovascular disease, and heart failure, are much worse in patients who are not treated, even in the ninth decade of life.

What Is the Best Antihypertensive Drug for an Elderly Person With High Blood Pressure?

In general, the same medications recommended for the general population are usually appropriate for the elderly individual. The ALLHAT trial (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack) showed that alpha-blockers were associated with greater risk for cardiovascular events like heart failure compared to other drug classes. However, for most elderly patients with another medical condition, experts seem to agree that treatment should be individualized based upon the patient’s needs.

Medical problems like kidney disease, gout, diabetes, osteoporosis, and heart failure will directly influence the choice of drug used to control blood pressure, particularly when another condition can be treated with the same drug used for hypertension. Multiple medical conditions in elderly patients require expert advice from a clinician to determine what blood pressure medication will best meet the individual’s needs.

High blood pressure may be more difficult to control in an older person and more than one drug is frequently prescribed. This can result in "orthostatic hypotension," or a drop in blood pressure when moving from a reclining or seated position to a standing position. It is especially important to measure an older person's blood pressure when they are standing to be certain it does not become too low and cause fainting or dizziness. Orthostatic hypotension is a significant fall risk in the elderly and because older patients often take many types of medication, they may also interact and increase this type of effect.

The American Geriatrics Society recommends screening for frailty in older individuals to identify any risks associated with aggressive blood pressure treatment, including the risks of falls and fatigue. Most experts also agree that lowering blood pressure with medication in elderly patients should occur slowly, with gradually increasing dosage. Although blood pressure guidelines currently suggest starting two different drugs when the initial blood pressure is more that 20 mm Hg over the target, one medication should be started slowly before adding a different drug.

Other Considerations

As we age, we lose some sensitivity to taste, so older people may oversalt their food without realizing they are increasing their risk. Sleep apnea is associated with development of hypertension, so it is reasonable to mention unusual drowsiness in the daytime or a feeling of fatigue on awakening when you are seeing your doctor.

As our population ages, we will continue to see a growing number of people who live into their 9th or 10th decade of life. In people over the age of 60, up to 80 percent will be affected by hypertension. Older adults can extend and improve their quality of life by reducing the risk of stroke, heart attack, heart failure, and death through control of blood pressure. The Joint National Commission (JNC8) recommendations have presented the best evidence available in their recommendations for control of hypertension.

A Word From Verywell

Treatment of high blood pressure can extend your lifespan and reduce the risk major catastrophic events like stroke or heart attack. Older patients benefit more than younger patients by treatment of hypertension. They are also likely to have other medical conditions and they may have an increased risk of adverse medication effects. If you are an older individual with hypertension, you should consult a healthcare professional who is knowledgeable about its treatment. The ideal healthcare professional will also have a comprehensive understanding of the functional challenges that come with aging and the many co-morbid medical problems prevalent in the elderly population.

Sources:

American Academy of Family Physicians. (2014). JNC 8 Guidelines for the Management of Hypertension in Adults. Am Fam Physician90(7), 503-504.

Franklin SS, Gustin W 4th, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997; 96:308.

James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC, Svetkey LP, Taler SJ, Townsend RR, Wright JT, Narva AS,

Ortiz E. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in AdultsReport From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA.2014;311(5):507-520. doi:10.1001/jama.2013.284427

Mahajan R. Joint National Committee 8 report: How it differ from JNC 7. International Journal of Applied and Basic Medical Research. 2014;4(2):61-62. doi:10.4103/2229-516X.136773.

Patel MD, A. (2015, February 20). On Hypertension in the Elderly: An Epidemiologic Shift - American College of Cardiology. Retrieved from http://www.acc.org/latest-in-cardiology/articles/2015/02/19/14/55/on-hypertension-in-the-elderly

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