Hypertension in the elderly
With age, the prevalence of hypertension increases dramatically, so by the age of 70, most people suffer from this disease. The elderly age group is the fastest growing segment of the population suffering from hypertension, and the magnitude of this problem is usually not evaluated.
In the Framingham Heart Study, hypertension eventually developed in more than 90% of participants with normal blood pressure at the age of 55. By age 60, approximately 60% of the population suffers from hypertension; by age 70, about 65% of men and about 75% of women suffer from hypertension.
The disease can be hidden, but in older people hypertension is most often manifested by symptoms such as headache, dizziness, weakness, and rapid heartbeat. When measuring blood pressure is determined by the increase in the upper or upper and lower indicators. Treatment can reduce the risk of life-threatening complications.
Video: Hypertension in Elderly people
Features of blood pressure measurement in the elderly
A key component of optimizing blood pressure management is the measurement of blood pressure and pulse in an elderly person.
Measurement of blood pressure allows you to:
- Diagnose hypertension.
- Determine how serious it is, which helps decide how important medical intervention is.
- Assess how well people respond to the treatment plan, and whether the plan includes changes in lifestyle, medication, or both.
BP may be determined in the doctor’s office, during home monitoring or even in a pharmacy. But in fact, studies have shown that a one-time measurement of blood pressure, for example, in the office often does not provide reliable data on human health. One study even showed that the “normal” method of measuring blood pressure allowed us to establish the wrong conclusion in 24-32% of cases. The reason for this lies in the fact that people often worry when they are in the doctor's office, so the blood pressure can rise temporarily.
Studies estimate that “white coat hypertension” affects 10–20% of people. In addition, blood pressure is constantly changing, even during the day, so experts agree that it is much better to get several readings and average them in order to correctly determine a person's reliable blood pressure.
For example, in the innovative SPRINT study on the intensive reduction of blood pressure in the elderly, participants' blood pressure was checked when they first had a quiet rest in a room for five minutes. Then the automatic monitor checked blood pressure three times in a row with an interval of one minute between each test. The average of these three readings was then used to assess blood pressure and make changes to the drugs for hypertension, if necessary.
Currently, the “gold standard” for assessing blood pressure is ambulatory blood pressure monitoring (ABPM). His conduct is based on wearing a special monitor that checks blood pressure every 15-60 minutes for 24 hours. The doctors then receive a report showing the average daily blood pressure and the average nightly blood pressure.
Outpatient monitoring provides excellent information for patients and doctors. In fact, studies show that ABPM is a better predictor of future cardiovascular events (for example, heart attacks, strokes) than conventional blood pressure measurements. However, ABPM is not yet widely available, as it requires special equipment and may require payment.
What is the best measurement? Studies show that measuring blood pressure at home is better than measuring blood pressure in conventional medical institutions. This means that home blood pressure measurements correlate better with blood pressure, which is measured by 24-hour outpatient monitoring.
Characteristics of hypertension in the elderly
In the elderly, hypertension is characterized by elevated systolic blood pressure with normal or low diastolic blood pressure. Such features are due to age-hardening of large arteries. This change in the structure of the artery system leads to an increase in the speed of the pulse wave. Thus, the reflected pressure waves are summed with direct pressure waves in the ascending aorta, which contributes to an increase in central systolic blood pressure.
In addition to the effects of high pressure on the coronary and cerebral arteries, the following changes occur:
- Increases the load on the wall of the left ventricle.
- Increased myocardial oxygen demand.
- Ischemia is increasing, which is often observed in old age.
In addition, the reflected waves of the blood flow affect the direct waves of the blood flow (i.e. stroke volume), which reduces cardiac output and, ultimately, blood flow in the organs. Such violations are especially harmful to the coronary, cerebral and renal circulation.
For older people, the changes presented are important. Hypertension is a potent risk factor for cardiovascular disease in the elderly. In most cases, hypertension preceded such complications as myocardial infarction, heart failure and stroke.
Observational studies show that mortality from coronary heart disease and stroke increases progressively and logarithmically, starting at the level of HELL 115/75 mm Hg.
For every 20 mm Hg. systolic or 10 mm Hg. diastolic increase in blood pressure there is a doubling of mortality from both coronary heart disease and stroke . These increased risks persist for at least the ninth decade of life.
Video: CARDIOVASCULAR SYSTEM IN ELDERLY POPULATION
Basic principles of treatment of hypertension in the elderly
Numerous randomized studies have shown a significant reduction in outcomes of cardiovascular diseases in groups of patients aged 60 to 79 years old with antihypertensive drug therapy. A similar response rate seems to be similar to that observed in younger cohorts.
The effect on mortality for various reasons was insignificant, but still antihypertensive therapy reduced the risk of death from all causes by more than 20% in people aged at least 80 years.
Despite the fact that in recent years there has been an increase in the level of treatment and control of blood pressure among adults with elderly hypertension, the indicators of blood pressure control remain suboptimal in the elderly. Data from the National Health and Nutrition Survey 2005-2006 (NHANES) show that for people over 60 years old, blood pressure control indicators are less than 50%.
Treatment of hypertension in the elderly is carried out with the following features:
- The elderly have a higher absolute risk of cardiovascular disease compared with younger people with the same risk factor profile.
- The elderly are more prone to higher systolic blood pressure and higher prevalence of isolated systolic hypertension.
- Older people are more likely to have comorbidities that directly affect the choice of antihypertensive drug therapy.
Older people are most often strongly recommended non-pharmacological measures to maintain lifestyle, which can slow the development of hypertension. Also, if necessary, additional therapy is used in patients with established hypertension.However, most elderly hypertensive patients are treated with several antihypertensive drugs to reduce blood pressure.
Although the specific blood pressure at which antihypertensive therapy should be started in older people is unclear, it is most often followed by a threshold of 140 mmHg. / 90 mmHg in persons aged 65 to 79 years and systolic blood pressure of 150 mm Hg. in people aged 80 and over.
Although the optimal goal of treating blood pressure in the elderly has not been determined, it is most often carried out to the next level
- Less than 140 mmHg Art. / 90 mmHg Art. in persons aged 65 to 79 years.
- From 140 mm Hg Art. to 145 mm Hg. systolic blood pressure at the age of at least 80 years.
Diuretics, ACE inhibitors, angiotensin receptor antagonists, calcium antagonists and beta-blockers have shown advantages in terms of the results of cardiovascular diseases. Similar findings were made based on randomized trials in the elderly. Thus, the following indicators are the basis for the selection of specific drugs:
- The effectiveness of the drug.
- Tolerability of the drug.
- The presence of specific associated diseases.
- Cost of funds.
The high prevalence of comorbidities without cardiovascular complications in the elderly requires special vigilance. This will avoid the side effects associated with the treatment. Orthostatic hypotension is a particularly common manifestation of autonomic dysregulation observed in elderly people with hypertension. This side effect not only limits lifestyle, but is also associated with an increase in the number of adverse events.
Drug treatment of hypertension in the elderly
There are such antihypertensive drugs that belong to the first line, therefore, are appointed first.
Thiazide diuretics are considered the preferred antihypertensive agent. They reduce morbidity and mortality from the following complications:
- Disorders of cerebral circulation.
- Chronic heart failure.
- Myocardial infarction.
The only side effects of thiazide diuretics can be side effects such as dehydration, orthostatic hypotension, hypokalemia, and if necessary, a combination with a potassium-saving diuretic is performed.
Second-line antihypertensive drugs are prescribed when first-line drugs have proven ineffective. Beta-blockers, ACE inhibitors and calcium channel blockers are most commonly prescribed.
Atenolol and metoprolol are most commonly prescribed from beta blockers. When used properly, they reduce morbidity and mortality in the elderly. The only thing to be used with caution in vascular diseases and chronic heart failure.
An ACE inhibitor or angiotensin receptor blockers are often used for coronary artery disease, ventricular pathologies, diabetes, and so on. Side effects can cause dehydration or decrease blood volume, as well as heart failure, renal artery stenosis.
Calcium channel blockers are often considered in the treatment of coronary heart disease and diabetes. Sometimes complicated by orthostatic hypotension in patients receiving nifedipine.
It is important to know that clonidine-type central alpha-adrenergic stimulants should be used with caution as they can cause drowsiness, dry mouth, depression, hypotension, recurrent hypertension if the drug has been abruptly canceled.
Traditional methods of treatment of hypertension in the elderly
First of all, measures should be taken to effectively control blood pressure. In particular, you can use in practice the following recommendations:
1. It is important to provide high-quality home monitoring of blood pressure.
This will always keep abreast of health status, while it will not need to specifically visit the clinic.
2. Check the level of blood pressure should be twice a day, every day for one week.
It is worth remembering that the blood pressure in the body is constantly changing, and sometimes quite significantly, so checking the blood pressure for several days in a row will allow you to get several values that can be averaged.
It should strive to check blood pressure at the same time every day. On average, several daily measurements provide a more accurate picture of the value of blood pressure in humans.
Testing in the morning and in the evening is recommended by many experts. This is because blood pressure can change throughout the day, especially in people who take medications for hypertension. But if measuring twice a day seems too difficult, you need to check at least once a day.
Researchers also often talk about the need to check blood pressure in the morning before taking any medication.However, if there are any concerns about a sharp drop in blood pressure, you need to review the testimony made about an hour after taking the medication. This will make sure that blood pressure does not drop too low after a person takes medicine.
Optional, but useful: use the “three dimensions in a row” technique whenever possible. For example, in the SPRINT test, blood pressure was measured by the participants after a quiet rest for five minutes. Then, the device checked the blood pressure three times in a row with a pause of one minute between each test. The results of the three measurements were averaged and the index was obtained per day.
Some home blood pressure monitors (such as the Omron 786N) have a feature that allows triple testing quickly and easily. In Omron, this option is called “TruRead”.
3. It is necessary to make a list of all medications.
The attending physician should be aware of the drugs that his patient is taking. This will help him make a more effective treatment plan. In particular, the list should include:
- All medications are taken to treat the heart or blood pressure.
- The remaining drugs, because some of them, which are not designed to control blood pressure, can still affect pressure (for example, Flomax, often used to improve urination, when a man has an enlarged prostate).
- All supplements, vitamins, herbs and OTC drugs.
- Medicines that are not taken as prescribed. It is especially important for doctors to know whether an elderly person has missed any medications that affect blood pressure.
Additionally, you need to pay attention to any problems associated with side effects, cost or other issues that may affect the continuation of treatment.
4. It is necessary to list ways to reduce blood pressure, which are obtained to comply with or who are interested
Prescription drugs are the main treatment for hypertension. But while many lifestyle changes also help reduce blood pressure. If you want to tell the doctor which of them is used in practice, you need to indicate this. You should also tell your doctor if you are interested in including any type of treatment in your hypertension management plan.
Many of the current lifestyle changes are important for older people because they benefit health in many ways. At the same time, there are less risks associated with poor health than prescription drugs.
Proven approaches to lowering high blood pressure are as follows:
- Weight loss.
- Physical exercise.
- DASH Diet (Dietary approaches to stop hypertension).
- Reducing sodium (salt) intake, especially in people who are sensitive to it.
- Lack of smoking and alcohol.
Additional recommendations may be given after medical examination and instrumental studies.
Hypertension is widespread among the elderly and is a major risk factor for cardiovascular diseases. As a rule, in elderly patients an increase in systolic blood pressure with low diastolic blood pressure (due to “hardening of the arteries”) is observed.
Numerous concomitant diseases of hypertension make the management of the disease very difficult, but possible. Data from various studies confirm the positive properties that can be obtained by reducing blood pressure in the elderly.
Lifestyle modification is very useful, even if it is an additional measure of impact to drug therapy. It is important to know that you need to start with low doses of the drug, which, if necessary, slowly increases. For people aged at least 80 years old, systolic blood pressure of 140 mmHg is acceptable. Art. to 145 mm Hg. Art.
Video: What is the normal blood pressure for your age?