HYPERTENSION IN THE ELDERLY

Syakib Bakri
 ELDERLY

> 65 YEARS
POPULATION : Notice the increase in the
elderly population as the baby – boomers age
PERCENT ELDERLY BY AGE 2000 – 2030
IN AMERICA ( U.S. CENCUS 2000 )

25

20
> 65
15
> 75
10

5 > 80

0
2000 2015 2030
21,9% 25,2% 35,1%
 INDONESIAN ELDERLY POPULATION
( > 65 YEARS )
Ind. Cencus 1971, 1980, 1990, 1995 and 2000
10
9
8
7
6 4,75%
5 4,25%
3,88%
4 3,25% >65
2,51% years
3
2
1
0
1971 1980 1990 1995 2000 Biro Pusat Statistik
Indonesia
 Aging is NOT a disease
Aging is a universal process.
Many elderly have arthritis, or
dementia, or hypertension
But not everyone gets the same
disease
Disease is not a necessary part of
aging
 Principal Effects of
Aging on the Cardiovascular System
• Increased arterial stiffness
• Increased myocardial stiffness
• Impaired β-adrenergic responsiveness
• Impaired endothelial function
• Reduced sinus node function
• Decreased baroreceptor responsiveness

• Net effect: Marked reduction in CV

reserve
Systolic BP rises continuously with age
Diastolic BP rises continuously until age 60-70
years
It falls thereafter as a consequence of increased
arterial stiffness

Systolic Hypertension
Pulse pressure increases continuously with
age
Smulyan H, Safar ME. Ann Intern Med. 2000;132:233-237.
 Pathophysiologic changes associated
with hypertension in the elderly (1)
Hemodynamic alterations
Increased peripheral vascular resistance
Decreased cardiac output
Decreased heart rate
Changes in cardiovascular structure and function
Decrease in vascular compliance
Increase in media-lumen ratio
Decreased myocardial contractility
Left ventricular hypertrophy
Diastolic dysfunction
 Pathophysiologic changes associated
with hypertension in the elderly (2)
Impairment of renal function
Decreased renal perfusion
Reduced glomerular filtration rate
Neurohormonal alterations
Decreased plasma renin activity
Decreased baroreceptor sensitivity
Glucose intolerance
Increased plasma catecholamine levels (decreased
adrenoreceptor sensitivity)
 Framingham – Study
Blood pressure and age
160
Women
150 Men
Systolic BP
140
BP (mmHg)

130
120
90

80 Men
Diastolic BP Women

70
36 41 46 51 56 61 66 71 76 81 Years age
Kannel et al 1978
 SBP, But Not DBP, Increases
Throughout Life

Blood Pressure (mm Hg)

With age, SBP increases, 160 SBP
while DBP tends to decline 140
– SBP increases in linear fashion 120
– DBP rises less steeply, plateaus, and 100
declines 80 DBP
slightly after the seventh decade
60

15–24 25–34 35–44 45–54 55–64 65–74 75–84

85–99
Age Group (y)

Galarza CR et al. Hypertension. 1997;30:809-816.

 O L D P A R A D I G M
Normal systolic blood pressure for older persons
was “100 plus the person’s age”.
Isolated Systolic Hypertension : wide pulse
pressure hypertension
associated with normal or low DBP
 Peripheral (radial) pressure waveforms recorded noninvasively by
applanation tonometry, and synthesized central (aortic) waveforms
from a young subject (A, B,).

Vlachopoulus C, O’Rourke M. Curr Hypertens Rep 2000 ; 2 : 274.

 Peripheral (radial) pressure waveforms recorded
noninvasively by
applanation tonometry, and synthesized central (aortic)
waveforms
from subject (C,D) with isolated systolic hypertension
(ISH, lower waveforms).

Vlachopoulus C, O’Rourke M. Curr Hypertens Rep 2000 ; 2 : 274. 13 R

Development of aortic pressure abnormalities due to
age-related aortic stiffening

Smulyan H, Safar ME. Ann Intern Med. 2000;132:230.

 Elevated Systolic Blood Pressure
as a Risk Factor for
Cardiovascular and Renal Disease

He J & Whelton PK
J Hypertens 1999 ; 17 (Suppl 2) : S7-S13.
 SBP-Associated Risks: MRFIT
SBP versus DBP in Risk of CHD Mortality
80.6

48.3

CHD Death Rate 37.4

43.8
34.7
31.
0 38.1
25.5
23.8
24.6
25.3
25.2
20.6 16.9
2 4 .9
13.
9
10.3 12.8
11.8 12.6
100+ 11.8 160+
8.8
90–99 8.5 140–159
80–89 9.2
75–79 120–139 Systolic BP
Diastolic BP 70–74
<70 <120 (mm Hg)
(mm Hg)

Neaton JD et al. Arch Intern Med. 1992;152:56-64.

 Relationship between cardiovascular risk and
systolic blood pressure

Risk estimates for all cardiovascular end-points based on three large therapeutic trials (n=7929) as a
function of systolic bloodpressure. Note that the risk increases with the level of systolic blood
pressure (SBP). However, at any given value of SBP, the risk is higher when diastolic blood pressure
(DBP) is lower.
Safar ME. Curr Opin Nephrol Hypertens 2001, 10:257-261
Syst. BP and CV risk in older people
in comparison with younger people

65 – 94 years 35 – 64 years
Prevalence of Hypertension by age in
general population of the U.S.
1988-1991.
Age Percentage (%)
18 – 29 4
30 – 39 11
40 – 49 21
50 – 59 44
60 – 69 54
70 – 79 64
80 65
Swales JD. 1994.
 Prevalence of Hypertension
increase with advancing age
70
prevalence of hypertension (%)

SBP > 140 mm Hg 65

60 64
DBP > 90 mm Hg
50 54

40 44

30
20 21
10 4 11
0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 Blood Pressure Classification
( JNC VII, 2003 )
BP SBP DBP
Classification mmHg mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

Hypertension
Stage 2 >160 or >100
Hypertension
JAMA. 2003;289
 Distribution of Hypertension Categories
by Age and Sex
IDH Combined Stage 2 ISH Stage 1 ISH
MEN WOMEN
100 100
90 90
80 80
70 70
60 60
% %50
50
40 40
30 30
20 20
10 10
0 0
30-39 50-59 70-79 30-39 50-59 70-79
40-49 60-69 80-89 40-49 60-69 80-89
Age Age
Sagie,Larson, Levie : N Engl J Med 1993; 329.
 Other characteristics of
Hypertension in the Elderly
Frequent occurrence with
other complications and disease states
Frequent association Altered renal function
with CV disease and Frequent diabetes
heart failure
 ELDERLY
OTHER RISK
HYPERTENSION
FACTORS
?

OTHER DISEASE or
COMPLICATION

STROKE & CORONARY HEART DISEASE

PROGNOSIS ?
 Benefits of Lowering BP in the
Elderly
MRC
SHEP STOP-1 (N
(N =
(N = 4736) = 1627)
2394)
BP Reduction (mm Hg) 12/4 20/8 12/5
Results (% reduction)
Total mortality 13 43* 3
All stroke 37* 47* 25*
CHD 25* 13† 19
All CV events 32* 40* 17*

*P < 0.01.
†
Myocardial infarction only.
Hansson L. Cardiovasc Drugs Ther. 2001;15:275-279.
 Benefits of Lowering Isolated
Systolic Hypertension in Patients
60 Years
Syst-Eur Syst-China
Results (% Reduction) (N = 4695) (N = 2394)
All CV endpoints 31* 37†
Stroke 42* 38†
All cardiac endpoints – 37‡

*P < 0.003; †P  0.01; ‡P = 0.09.

Liu L et al. J Hypertens. 1998;16:1823-1829.
Staessen JA et al. Lancet. 1997;350:757-764.
Because elderly patients are at much
higher risk of cardiovascular disease
than younger patients with mild
hypertension,

treatment of elderly
hypertensives prevents
more events than similar
treatment in younger
patients.
How to control ??
 JNC VII ( 2003 )
Elderly population has the lowest rates of
BP control.

Treatment, including those who with

isolated systolic HTN, should follow same
principles outlined for general care of HTN.

Lower initial drug doses may be

indicated to avoid symptoms; standard
doses and multiple drugs will be needed
to reach BP targets. JAMA. 2003;289
 Lifestyle Modifications to
Prevent and Manage Hypertension
• Reduce weight • Moderate consumption
of:
• alcohol
• sodium
• saturated fat
• cholesterol
• Maintain adequate intake of
• Increase dietary:
physical • potassium
activity • calcium
• magnesium
• Avoid tobacco

(JNC VI. Arch Intern Med. 1997)

JNC VII Lifestyle modification
2003

Not in goal BP
( < 140/90 mmHg or < 130/90 mmHg for those
with DIABETES or CHRONIC KIDNEY DISEASE )

Initial Drug Choice

Hypertension Hypertension
Without With
Compelling indication Compelling Indication

JAMA. 2003;289
JNC VII Hypertension
2003
Without
Compelling indication

Stage 1 Hypertension Stage 2 Hypertension

Syst. 140 – 159 OR Syst. > 160 mmHg OR
Diast. 80 – 90 mmHg Diast > 100 mmHg

Thiazide type diuretics 2 Drug Combination

for most for most
May consider ACE inh, Usualy thiazide type with
ARB, CCB, Betablocker ACE inh. or ARB or Beta
Or Combination Blocker or CCB

JAMA. 2003;289
JNC VII
2003

Not at goal BP

Optimize dosage or add additional drugs

Until goal BP is achieved

Consider Consultation with Hypertension Specialist

JAMA. 2003;289
 Goals of treatment
JNC VII ( 2003 ) : @ < 140 / 90 mmHg
or < 130 / 80 mmHg for those
with Diabetes or Chronic Kidney
disease.
@ Achieve SBP goal especially in
persons >50 years of age.

EUROPEAN SOCIETY of HYPERTENSION ( 2003 )

: @ At least below 140 / 90 mmHg
( lower values if tolerated )
@ Below 130 / 80 mmHg in Diabetics.
@ Keeping in mind, however, that
systolic below 140 mmHg may be
difficult to achieved in elderly( more flexible )
 Guidelines for Drug Therapy in
Hypertensive Elderly
• Start with small dose, usualy half of adult dose.
• Attemp to reduce blood pressure slowly, perhaps by no more than
10 mmHg per month, to allow for autoregulation to maintain
perfusion to vital organ.
• Bringing the systolic blood pressure to near 140 mmHg while
insuring that the diastolic pressure is not lowered much below
70 mmHg.
• Anticipate side effect and monitor them by questioning and
appropriate laboratory test.
• Home of the blood pressure should be encouraged to ensure that
treatment is adequate but not excessive.
Kaplan NM. Circulation 2000 ; 102 : 1079-1081.
Tjoa HI, Kaplan NM. JAMA 1990 ; 164 : 1015-1018.
 Pathophysiologic changes associated
with hypertension in the elderly (1)
Hemodynamic alterations
Increased peripheral vascular resistance
Decreased cardiac output
Decreased heart rate
Changes in cardiovascular structure and function
Decrease in vascular compliance
Increase in media-lumen ratio
Decreased myocardial contractility
Left ventricular hypertrophy
Diastolic dysfunction
 Pathophysiologic changes associated
with hypertension in the elderly (2)
Impairment of renal function
Decreased renal perfusion
Reduced glomerular filtration rate
Neurohormonal alterations
Decreased plasma renin activity
Decreased baroreceptor sensitivity
Glucose intolerance
Increased plasma catecholamine levels (decreased
adrenoreceptor sensitivity)
 Classes of
Antihypertensive Drugs

• ACE inhibitors
• Angiotensin II receptor blockers
• Beta-blockers
• Calcium antagonists
• Central Sympatolitic
• Direct vasodilators
• Diuretics
ACE inhibitors, Beta blockers, Calcium blockres &
diuretic for the control of systolic Hypertension.

n P

Placebo 66 NS

ACE inhibitors 62 0,005

Beta blockers 46 NS
Calcium blockers 65 0,0005

Diuretics 65 0,0005

Morgan TO, et al. Am.J.Hypertens. 2001 ; 14 : 241 - 247

Systolic and diastolic blood pressure and pulse rate
achieved with each class of drug

Mean  SEM.
P is paired t test with placebo with Bonferoni correction.
Where two p values are given the second is without the correction.
Morgan TO. Am J Hypertens 2001 ; 14 : 241-247.
Morgan TO. Am J Hypertens 2001 ; 14 : 241-247.
 New Approach in The Treatment of
Isolated Systolic Hypertension

Antihypertensive drugs which reduce systolic blood pressure

more markedly than diastolic blood pressure :

• Aldosterone antagonist :
Spironolactone
Eplerenone
• Long acting nitrate
• Vasopeptidase inhibitors

van Zwieten PA. Nephrol Dial Transplant 2001 ; 16 : 1095-1097.

The elderly use more drugs because illness
is more common in older persons,
especially arthritis, cardiovascular and
gastrointestinal disorders, and bladder
dysfunction

The high cost of medication is frequently

an economic burden on elderly persons
living on a fixed income
Studies have shown that persons over
age 65 use 2 to 6 prescription drugs and 1
to 3.4 over-the-counter medicines

The term polypharmacy means "many

drugs" and is used to indicate the use of
more medication than is clinically
indicated or warranted
 Care in prescribing, including a careful,
thorough medication history and periodic
drug review, are important factors in
reducing polypharmacy and its adverse
effects, especially in ELDERLY
Problema in the measurements of blood
pressure in the elderly

Pseudohypertension
Office hypertension (white coat hypertension)
Orthostatic hypotension
14 R