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Quality of Life in The Elderly Hypertensive: Maria I. Nunes
Quality of Life in The Elderly Hypertensive: Maria I. Nunes
Quality of Life in The Elderly Hypertensive: Maria I. Nunes
Introduction
In most industrialized countries, the mean life expectancy is increasing hence the increase in the elderly
population. The very elderly, people aged 80 years and
over, is the fastest growing segment of the population
w1x. Cardiovascular disease is the leading cause of death
among elderly people in developed countries w2x and
experimental data from clinical trials has clearly demonstrated the benets of treating hypertension in patients
aged 6079 in reducing cardiovascular morbidity and
mortality.
Demographic changes have led to an increase in the
importance of chronic disease as part of the health
experience of the population, therefore the emphasis is
no longer on cure but on living with an on-going disorder w3x. Therefore the assessment of quality of life is
becoming increasingly more recognized as an essential
outcome measure for hypertensive patients. In the very
elderly 80 q ., due to the limited amount of experimental data, the benet of treating this age group is not
clearly demonstrated w4x. However, trials targeting this
age group are under way and should provide evidence
as to whether it is worth treating the very elderly
hypertensive.
subjects do not benet. Moreover, it has been suggested that the treatment of hypertension in elderly
hypertensives might have an adverse effect on cognition, mood, or leisure activities w15x. Therefore, the
effect of treatment on measures of quality of life requires consideration, since the benets should clearly
outweigh the risks, especially in the elderly where a
small reduction in health could limit their activities of
daily living.
Non-pharmacological intervention
It has been recommended that when possible, nonpharmacological means such as weight loss, limitation of
alcohol intake, reducing sodium intake and increasing
physical activity should be the rst method employed
to reduce hypertension in the elderly w4,7,16x. However,
the general perception is that elderly patients are more
resistant in following lifestyle therapy w16x, although the
Trial Of Non-pharmacologic interventions in the Elderly TONE. reported that change in lifestyle can be
achieved in this age group w17x.
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Diuretics
The existing clinical data on low-dose diuretics has
shown that they are efcacious, inexpensive, and well
tolerated, especially in the elderly w21x. The Systolic
Hypertension in the Very Elderly Program SHEP. trial
was a multi-centre, randomized, double-blind, placebocontrolled trial of patients 60 years or older. The trial
was designed to compare the effect of diuretic and
-blocker-based antihypertensive treatment on isolated
systolic hypertension ISH.. The 4736 participants were
randomized to either active hypertensive drug or matching placebo. The trial was also designed to assess the
impact of the antihypertensive treatment on measures
of cognitive, emotional, and physical function and
leisure activities. The SHEP behavioural evaluation was
administered after randomization and before treatment
started. Cognitive impairment, depression, and mood
disorders were evaluated twice a year and measures of
activity of daily living and social network were assessed
once a year. In addition, once a year subjects in six of
the 16 clinical centres involved in the trial, received
more detailed tests of cognitive function, including
psychomotor speed, attention span, visual scanning,
mental calculation, expressive language function, verbal
memory, and hypothesis testing. The results demonstrated that medical treatment of ISH decreases the
incidence of cardiovascular events without causing deterioration on measures of quality of life. The results also
reported, for some measures, a small positive effect on
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Beta-blockers
In a review of several randomized quality of life trials,
atenolol was compared to ACE inhibitors, diuretics and
verapamil, and the ndings revealed that there was no
difference in the change in QOL after treatment w8x.
In a recent study comparing bisoprolol with nifedipine
retard, although no statistically signicant difference
was found between the two groups at 8 weeks, the
analysis of the results of the last assessment usually 24
weeks. showed improvements in tensionranxiety,
angerrhostility, vigourractivity, and confusionrbewilderment in patients receiving bisoprolol w23x.
The SHEP trial used a -blocker as a second line
agent. Atenolol, when added to chlorthalidone, proved
to assist in the control of ISH. Also as mentioned
previously, treatment in the trial did not have a negative impact on measures of QOL.
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10 Bulpitt CJ, Fletcher AE. Antihypertensive drugs and quality of life in the
elderly. J Card Pharm 1989; Suppl 10:S21 S26.
At present there is insufcient evidence from randomized trials for or against treatment for those over 80.
Data on the effects of antihypertensive treatment on
QOL for this age group are also scarce. The Hypertension in the Very Elderly Trial HYVET. is currently
under way and will address the issue of benetrrisk
comparison from active treatment. The HYVET trial is
a randomized, double-blind, multi-centre, placebo-controlled study w4x. The trial has included the assessment
of QOL and cognitive function as a side project.
It has been argued that available data on the treatment
of hypertension in the very elderly suggests that although treatment may not prolong life, or even shorten
it, by preventing non-fatal strokes it may have a benecial impact on quality of life w1,28x. However, each
scenario requires careful consideration w1x. The Study
on COgnition and Prognosis in the Elderly SCOPE. is
also currently under way and will be assessing the
impact of antihypertensive treatment on major cardiovascular events and on cognition and quality of life in
patients aged between 70 and 89 years w29x.
References
Conclusion
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