Hypertension (high blood pressure) is a very common condition in older Americans. It is estimated that about 65 percent of people older than the age of 65 (the elderly) have hypertension. This condition carries a very high risk for stroke and heart diseases. Although many studies have shown that controlling hypertension prevents complications like stroke, heart attack, heart and kidney failure, many elderly people continue to live with uncontrolled or inadequately controlled hypertension.
How is Hypertension in the Elderly Different from the General Population's?
There are at least two types of hypertension seen in this group. Classic essential hypertension is when both the systolic (top number) and the diastolic (bottom number) of a blood pressure (BP) reading are above the normal range (usually less than 140/90). Isolated systolic hypertension (ISH) is where only the top number is high while the lower number is normal (that is, upper number greater than 140 and lower number less than 90). The diagnosis of essential hypertension is made after an initial blood pressure of greater than or equal to 140/90 is repeated and confirmed over a period of two or more weeks. ISH is diagnosed when repeated measurements show the systolic BP is greater than 140, while the diastolic is less than 90.
In general, hypertension in the elderly increases the risk for stroke, heart attack, heart failure, kidney failure, and death. However, ISH is more common, more progressive, and associated with increased risk for these complications in the elderly more than regular hypertension.
Causes of Hypertension in the Elderly
Increasing age is associated with changes in the structure of walls of the blood vessels that make them less likely to give. These changes produce loss of vascular compliance, and it affects the size and volume of the lining of the arteries and ultimately results in hypertension. These biologic changes in the arterial caliber (diameter of the blood vessels) translate into overall cardiac dysfunction and to heart failure.
Treatment Considerations
We treat hypertension in the elderly to reduce the risks associated with it. Proper treatment will reduce death and disability from this disease. I usually consider two approaches in planning to treat hypertension in my elderly patients, lifestyle modification (exercise, diet, and smoking cessation), and drug therapy.
In my elderly patients with borderline hypertension (130-139/85-89) without any other medical problems, I usually recommend lifestyle modification as appropriate first step management for about six months. However, if the BP is borderline elevated and there is history of diabetes, kidney disease, heart failure, cigarette smoking, or previous heart attack, I usually start BP-lowering medication in addition to lifestyle modification. It is particularly important to start drug therapy early in elderly people with ISH because of the morbidity and mortality associated with it.
Lifestyle Modification
Lifestyle modifications are the common-sense things that are good for our physical and emotional health. Examples include not smoking, losing weight, staying active, reducing salt and fat from our diet, eating more fiber, calcium, potassium, and vitamins, and drinking alcohol in moderation. All these things have been shown to reduce BP alone or in combination with drugs. The types of exercise regimens I usually recommend for my elderly patients are moderate exercises (swimming, dancing, walking, and bowling) that do not necessarily involve vigorous activity. For example, walking three to five times a week for half an hour, at a rate of two to three miles per hour, can help them stay active, use up some calories, reduce weight and ultimately lower blood pressure. In terms of diet, a low-fat, high-fiber, low-salt, high-potassium, high-magnesium diet has been supported by many studies and authorities in hypertension as being ideal for controlling BP.
For example, I advise patients to maintain a healthy diet by eating lots of vegetables and fruits with low salt and high potassium content like bananas, spinach, watermelon, tomatoes, squash, beans, etc. Reduce daily salt (sodium) intake to two grams. I also ask them to choose a diet with reduced saturated and total fat, but high in fiber. The goal is for no more than 30 percent of calories to come from fat (about 20 percent from unsaturated fat and 10 percent from saturated fat). Foods like cereal, bread, pasta, and rice should be a significant part of daily meals. Certain kinds of fish, such as mackerel and salmon, have high content of omega-3 fatty acids that may help lower BP, according to some studies. Sometimes my patients ask me how much alcohol is regarded as "moderate." The answer is that the effects of alcohol depend on several factors, such as our body size and genetics (family histories). However, limiting alcohol intake to fewer than 24 ounces of beer, two ounces of whiskey or ten ounces of wine a day is an appropriate target for the average male and about half of these amounts for thin people and most women. Studies have shown that the benefit of alcohol (one drink a day) in heart disease is only seen in women over the age of 55 and men over the age of 45.
Lifestyle modification benefits
My elderly patients are often concerned about their age making them susceptible to injuries during exercise, that weight loss will increase their risks of osteoporotic fractures (especially elderly women), and that food restriction will lead to poor nutrition. The consensus is that with a focused, guided program of lifestyle modification, there is little risk compared to the enormous benefits, which include controlling hypertension and reducing the number and dosage of medications for hypertension.
Drug Therapy
When I am considering drug therapy for my elderly patients, the duration and severity of the hypertension in addition to other medical problems (co-morbid conditions), such as diabetes, kidney failure, or heart attack, usually influence my final choice. This approach helps me choose medication(s) that not only treat the increased blood pressure, but also helps in overall reduction of risks for heart diseases and stroke. Also, I try to base my choice of medication on evidence that such medication can prolong life and/or reduce disability from hypertension.
Heart disease
In elderly patients without any other risk factors for heart disease, I prefer low-dose diuretics such as thiazide agents (hydrochlorothiazide or chlorthalidone) as first-line drug therapy. For elderly patients with history of angina, prior heart attack, or irregular heartbeats (atrial fibrillation), a beta-blocker (Atenolol, Bisoprolol, or Metoprolol) is usually the agent I use. These drugs, in addition to reducing blood pressure, reduce the amount of work the heart has to do by lowering heart rate. The function of these drugs are important in preventing second heart attacks and dangerous abnormal heartbeats (arrhythmias).
Diabetes, heart failure, and chronic lung disease
If there is history of diabetes, heart failure, or chronic lung disease, the medication of my first choice is usually one of the Angiotensin Converting Enzyme Inhibitors (ACEIs) such as Lisinopril, Enalapril, Ramipril or Captopril or the Angiotensin-Receptor Blocker (ARBs) such as Losartan, Irbesartan or Candesartan. In addition to lowering BP, the ACEIs have been shown to prolong life, improve exercise tolerance, and reduce the level of angiotensin II in the blood (angiotensin II has negative effect to the functions of the heart). These agents decrease the progression of kidney failure and protein in the urine (proteinuria) in elderly hypertensive patients with diabetes. Severe chronic lung disease may be a relative contraindication to the use of antihypertensive agents like beta-blockers, and ACEIs are good alternatives in such elderly patients.
Although some clinical studies have found the ARBs to be effective in controlling blood pressure, they have not been around as long as the ACEIs and clinical trials comparing effects and benefits ARBs to ACEIs in a large number of patients are still ongoing. Many doctors do not use them as first-line agents at this point. I use the ARBs in my elderly patients with hypertension and heart failure if they cannot tolerate the ACEIs due to persistent cough, change in taste or they develop a rash. In those elderly (male) patients with benign prostatic hyperplasia (BPH) and hypertension, I use any of the alpha-adrenergic blockers (drugs such as Doxazosin, Prazosin or Terazosin) that reduce the symptoms of BPH as well as control BP.
Monitor your blood pressure
I advise my patients to have their own blood pressure machines at home and to measure their blood pressures once or twice daily (morning hours and evenings). This helps in several ways; it motivates them to take their medicines, helps monitor differences in blood pressure at different times of the day, and it helps monitor the effectiveness of the medications.
In my elderly patients on anti-hypertensive drugs, close monitoring of blood pressures, liver function tests, kidney functions and other electrolytes are particularly important. This is because elderly patients are more likely to get hypotension (low blood pressure), drug toxicity due to age associated bodily changes such as decreased kidney and liver functions, and drug interaction due to use of many other medications.
Conclusion
Close blood pressure monitoring is important in the elderly for early diagnosis and prompt initiation of therapy. It is particularly important to diagnose and treat ISH as early as possible given the high incidence of stroke, heart attack, and heart failure associated with this type of hypertension. Medical treatment should always be accompanied by lifestyle modification in the elderly. Focused and guided lifestyle modification is safe for the elderly. Choice of medications should be based on both their antihypertensive effects and their ability to reduce overall risks for heart failure, myocardial infarction (heart attack), kidney failure, stroke etc. Home BP monitoring will help follow BP fluctuations during the day and may motivate some elderly patients to take their medications as they become involved in their illness. Electrolytes (potassium and magnesium) and kidney function (creatinine) should be followed closely given the propensity of the elderly to suffer drug toxicity and adverse effects. In addition to reducing human suffering and saving lives from complications associated with hypertension, adequate control of hypertension in the elderly will reduce the economic burden associated with these complications.
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