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The Art of Blood Pressure Management in the Elderly

The Art of Blood Pressure Management in the Elderly. Dr. Sheri-Lynn Kane St. Joseph’s Health Centre,Guelph Geriatrician Assistant Clinical Professor McMaster University. Overview. Why do we treat hypertension? Why not just apply the evidence to everyone?

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The Art of Blood Pressure Management in the Elderly

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  1. The Art of Blood Pressure Management in the Elderly Dr. Sheri-Lynn Kane St. Joseph’s Health Centre,Guelph Geriatrician Assistant Clinical Professor McMaster University

  2. Overview • Why do we treat hypertension? • Why not just apply the evidence to everyone? • Special considerations in the elderly

  3. The Oldest-Old Boomsource: Stats Can 2002

  4. Physiological Changes with Aging • Increased vessel stiffness  decrease arterial compliance • Decreased baroreceptor sensitivity • Δ in β vasodilatation / α vasoconstriction balance favours vasoconstriction •  ability to handle salt

  5. Changes with Aging • Results in high prevalence of both • Combined hypertension > 140/90 • Isolated systolic hypertension >160 DBP <95

  6. End Organ Morbidity • Cardiovascular • MI • CHF – diastolic and systolic • PVD • Cerebrovascular • Dementia & Mild cognitive impairment • Stroke – hem and non-hem • Ocular disease • Renal failure

  7. Treatment • Trials in the “elderly” significantly: •  rate of stroke •  rate of CHF /CV end-point •  rate of dementia / cognitive impairment • Strong evidence for midlife hypertension linked to cognitive decline

  8. So why not just aim for target BP’s in everyone? • Evidence to date in those ≥ 85 variable • Many prospective, longitudinal studies show  mortality with “normal” or low BP’s ≥ 85 years • Those ≥ 85 yrs represents highly variable population  generalizability • Special considerations of BP in elderly

  9. Who: ≥ 80 yr with SBP ≥ 160 DBP≤ 110 mmHg Eastern Europe, China Not: accelerated HTN, CHF, dementia, nursing care, ↕ potassium, Cr > 150, gout

  10. What: DBPC, randomized, ITT Indapamide SR 1.5mg ± perindopril 2 or 4 target STANDING SBP <150 DBP<80 mmHg Outcome: fatal or nonfatal stroke death all cause, CV death, death CHF

  11. Bottom line • Curve shifts with the very old for normal • Still can decrease rate of stroke and CHF if applied to the right people • Need to be monitored more carefully to keep in optimal range • Dementia data pending

  12. Special considerations 87yo ♀ lives alone 3 falls in the last 6 months, pelvic F# HTN since 70’s, difficult to control No previous MI/stroke/TIA/CHF LVH by voltage ECG

  13. Meds: Eltroxin 0.15mg ECASA 325 mg Ezetrol 10 mg od Crestor 10 mg od Pindolol 5 mg od HCTZ 25 od

  14. Orthostatic Hypotension • Definition:  of 20/10mmHg SBP/DBP from supine to standing at 2 minutes • Prevalence 20% > 65 yrs community 30% >75 yrs community 50% in frail ±institution • Assoc with post-priandial hypotension

  15. Orthostatic Hypotension • ? Autonomic or non-autonomic • ?Symptomatic or asymptomatic • Consequences • Falls / fractures • Syncope • TIA • MI • Frailty /weight loss •  mortality

  16. 87yo ♀ lives alone 3 falls in the last 6 months, pelvic F# HTN since 70’s, difficult to control No previous MI/stroke/TIA/CHF LVH by voltage ECG Meds: Eltroxin 0.15mg ECASA 325 mg Ezetrol 10 mg Crestor Pindolol 5 mg od HCTZ 25 od

  17. Special considerations 80 yo♀ lives alone Longstanding refractory hypertension Meds: Altace 10mg od Norvasc 5 mg bid - to bid 3 months ago HCTZ 25mg od BP 188/88 both arms in any position, light headed with standing “Feels awful”, multiple falls, losing weight

  18. Pseudohypertension Defn: • Artificial elevation of BP when measured by indirect cuff vs intra-arterial • Often associated with some hypertension • Due to stiff calcified vessels

  19. What to do? 80 yo♀ lives alone Longstanding refractory hypertension Meds: Altace 10mg od Norvasc 5 mg bid - to bid 3 months ago HCTZ 25mg od BP 188/88 both arms in any position, light headed with standing “Feels awful”, multiple falls, losing weight

  20. Loss of diurnal variations • ~ 20% HTN are non-dippers • > 50% of those with orthostatic hypotension • Cardiovascular events/100 pt-yr • 1.79 HTN dippers • 4.99 HTN non-dippers • 0.47 normotensive • Ambulatory BP helpful

  21. Summary • Need orthostatic BP’s in everyone • May need ambulatory monitoring • Need adequate control for degree of end organ damage • Titrate slowly one at a time on/off • Need more frequent monitoring • Need to avoid excessive lows especially ≥ 85yr / frail

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