Hypertension in older adults -
White coat hypertension WCH refers to in-office hypertension in the setting of normotension on ambulatory BP ABPM or home BP HBPM monitoring. An analysis from the SHEAF Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-up study revealed that among 4, elderly French adults mean age 70 years with treated hypertension, MH was present in 9.
elevated BP in both office and home HR 1. In this cohort of nearly 64, patients, ambulatory BP measurements were found to be a stronger predictor of all-cause and CV mortality.
These studies highlight the increased CV risk associated with MH and the relative uncertainty of the CV risk associated with WCH among older patients with treated hypertension. The threshold to use HBPM or ABPM should be low in older adults given the potential prognostic implications of these two phenotypes.
Recently, the Centers for Medicare Services approved additional coverage for ABPM in the older adult population. The Antihypertensive Treatment in Masked Hypertension for Target Organ Protection ANTI-MASK trial is a randomized, placebo-controlled trial seeking to evaluate the effects of allisartan isoproxil 80 mg once daily with a primary endpoint of improvement in the rate of target organ damage left ventricular hypertrophy, large arterial stiffness, and microalbuminuria.
The trial aims to recruit adults with a history of MH, but the recruitment status of the trial is unclear. The MASked-unconTrolled hypERtension Management Based on Office BP or on Out-of-office Ambulatory BP Measurement MASTER trial is currently recruiting patients to compare office BP vs.
Findings from these trials should provide some insights for monitoring and treatment of patients with MH. Special Considerations to Achieving Target Blood Pressure in Older Adults: Side Effects of Pharmacotherapy, Comorbidities, and Orthostatic Hypotension.
Antihypertensive agents like immediate release nifedipine and peripheral alpha1-antagonists doxazosin, prazosin, and terazosin are associated with a heightened risk of orthostatic hypotension while central alpha2-agonists like clonidine, guanfacine, and methyldopa can lead to significant central nervous system side effects in older adults.
Renin angiotensin system antagonists ACE-inhibitors, ARBs, or aliskiren and potassium sparing diuretics like amiloride or triamterene can lead to an increased risk of hyperkalemia.
A high degree of heterogeneity in clinical comorbidities, cognitive impairment, and variable life expectancy further add to the complexity of hypertension management in this patient population.
Among older patients with multiple clinical comorbidities, high frailty, or advanced cognitive impairment, an accurate assessment of prognosis, risk tolerance, and treatment goals is of paramount importance. Such patients typically reside in nursing homes and assisting living facilities; a population that is not represented in large RCTs and therefore have no demonstrated safety data for intensive BP lowering.
Hypertension is highly prevalent and frequently undertreated in older adults. Management of hypertension in this heterogenous population, including those with established CAD, atrial fibrillation, and stroke, requires a comprehensive assessment and shared decision making between clinician and patient that focuses on patient preferences, medical comorbidities, life expectancy, treatment goals, and an appropriate balance between risks and benefits.
Older Adults and Hypertension: Beyond the Guideline for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Feb 26, Anandita Kulkarni, MD, FACC ; Anurag Mehta, MD, FACC ; Eugene Yang, MD, FACC ; Biljana Parapid, MD Expert Analysis. Epidemiology of Hypertension in Older Adults Hypertension is one of the primary modifiable risk factors for cardiovascular CV disease and its prevalence and severity both increase with age.
Hypertension Guidelines Reviewed Hypertension guidelines published by several major medical societies highlight the challenges of managing BP in older patients. Figure 1. Figure 1: Adjusted hazard ratio as a function of age, systolic and diastolic blood pressure.
Reference systolic and diastolic blood pressure for hazard ratio: and 90mmHg, respectively. Blood pressures are the on-treatment average of all post baseline recordings. Figure reproduced from Denardo, et al.
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NW Washington , DC Email: membercare acc. org Phone: Toll Free: Fax: Diabetes: Respondents were categorized as having diabetes if the measured percentage of glycated hemoglobin A1c in their blood was equal to or greater than 6.
Sociodemographic characteristics included the following. Age group 60 to 69 and 70 to 79 was based on age at the time of the visit to the MEC. Marital status was defined as married or living common law, versus not. Highest level of education was defined as less than secondary school graduation, versus secondary school graduation or higher.
Household income was categorized as being in the lowest household income quintile, versus being above the lowest quintile. It was derived from total household income divided by the number of people in the household. White or non-white ethnicity was based on the respondent's answer to which racial or cultural group they belong.
Health behaviours included the following. Smoking status was classified as smoking daily or occasionally, versus not smoking.
Exercise was categorized as less than minutes per week of moderate-to-vigorous physical activity MVPA , versus or more minutes per week.
Fruit and vegetable consumption was categorized as five or more times per day, versus less than five times per day an indicator of diet quality. Comorbidity covariates included the following.
Respondents were overweight or obese if they had a body mass index BMI of Diabetes was determined as defined above. Note 25 Cholesterol was categorized as non-fasting non-high-density lipoprotein HDL cholesterol at or above 4. Note 26 Cardiovascular disease was defined as self-reported heart disease, heart attack or stroke.
Descriptive statistics were used to examine the characteristics of the study population and the prevalence of hypertension, treatment and control.
Logistic regression models were run separately for women and men to estimate the association between all covariates and hypertension control. Each model was rerun to test whether the age group modified the association between the covariates and hypertension control. All models included a CHMS cycle indicator.
Note 16 Note 17 Note 18 Note 19 The data were analyzed with SAS 9. Two sensitivity analyses were undertaken. Note 22 This allowed for comparability between the present study and others based on manual blood pressure readings.
This also allowed for comparability with other studies. Hypertension status could be determined for almost all respondents meeting the age criteria 4, , resulting in a study sample of 2, respondents with hypertension.
Among them, 2, respondents reported using antihypertensive medication. Of those treated with medication, 1, were controlled and were uncontrolled.
Figure 1 presents the prevalence of hypertension treatment and control among the hypertensive population by sex and age group. SBP values for women were higher across most of the distribution, regardless of age group or control status, compared with men Figure 2.
Women treated for hypertension were less likely than men treated for hypertension to be married or living common law, to smoke, to eat fruits or vegetables less than five times per day, to be overweight or obese, or to have diabetes or cardiovascular disease Table 1.
On the other hand, treated women were more likely than treated men to be in the lowest income quintile, to participate in less than minutes per week of MVPA , to have non- HDL cholesterol of 4.
Treated women were more likely to report using diuretics and NSAID s, and less likely to report using agents acting on the renin-angiotensin system or beta blockers. Among women, older age and diabetes were each associated with poorer hypertension control after covariate adjustment Table 2.
Age, ethnicity, diabetes, cardiovascular disease and NSAID use were each associated with hypertension control for men after covariate adjustment Table 2. The association between several characteristics and hypertension control varied between age groups. After covariate adjustment, white women aged 60 to 69 were more likely than non-white women to have their hypertension controlled, but this was not the case for women aged 70 to 79 Table 3.
Women aged 60 to 69 who smoked were more likely to have their hypertension controlled, and men aged 60 to 69 in the lowest income quintile were less likely.
These associations were not observed for women and men aged 70 to Applying the correction factors to adjust the average values of BpTRU TM SBP and DBP had little effect on the prevalence of hypertension results not shown or the prevalence of hypertension control Figure 3.
However, the prevalence of hypertension control for women and men increased Figure 3. In the regression analysis, removing the diabetes-specific threshold eliminated the association between diabetes and hypertension control for both women and men.
It also attenuated the association between hypertension control and ethnicity and cardiovascular disease for men results not shown. This study found that women and men aged 60 to 79 were equally likely to have hypertension. However, among those taking antihypertensive medication, almost one-third of women aged 70 to 79 did not have their hypertension controlled, a much higher percentage than for men.
The SBP of women was also higher than that of men, regardless of control. Older age and diabetes were significantly associated with poorer hypertension control for women, after covariate adjustment.
Older age, white ethnicity, diabetes, no cardiovascular disease, and NSAID use were associated with poorer hypertension control for men. Similar to other studies, Note 7 Note 13 this study found that the SBP of women was higher than that of men, regardless of age group or control status.
Furthermore, isolated systolic hypertension was more prevalent among women than men results not shown. Median SBP values for women were substantially higher than those for men at ages 60 to 69 a difference of 4 mmHg and at ages 70 to 79 a difference of 9 mmHg.
High SBP is of concern because of its significant association with the risk of cardiovascular and renal disease. Note Older age was significantly associated with poorer hypertension control among women and men—a finding that is consistent with other studies.
Note 6 Note 30 Age group modified the association between hypertension control and ethnicity and smoking for women, and between hypertension control and NSAID use for men. These results suggest that not only are women and men in older age groups at greater risk of poorer hypertension control, but that certain groups at older ages may be particularly at risk.
Studies have found that older adults with uncontrolled hypertension are at increased risk of mild cognitive impairment or probable dementia, accelerated decline in physical function, and increased incidence of disability. Cardiovascular disease was significantly associated with improved hypertension control in men and was 1.
Note 30 Similar to diabetes, existing cardiovascular disease is a strong predictor of recurrent events; therefore, hypertension control is emphasized, Note 4 resulting in improved patient adherence to treatment. Note 32 Note 33 Furthermore, medications such as agents acting on the renin-angiotensin system and beta blockers are recommended for people with cardiovascular disease, regardless of hypertension status.
Note 4 This study found that these therapies were more commonly prescribed for men. Diabetes was significantly associated with poorer hypertension control and was more prevalent in men. Poor hypertension control in people with diabetes has been observed in many other studies.
When the blood pressure targets for the general population were applied to people with and without diabetes in this study, hypertension control no longer differed between the two groups. The association of NSAID use with poorer control among men in the current study is consistent with the prohypertensive effect of these medications among those treated for hypertension.
Note 35 Note 36 Note 37 Note 38 This association was not observed among women. This may be related to their less frequent use of certain antihypertensive medication classes found to be susceptible to an interaction with NSAID s, namely agents acting on the renin-angiotensin system Note 35 Note 38 and beta blockers.
Note 37 Note This study has several strengths. The results are based on a nationally representative sample of respondents for whom SBP and DBP were assessed objectively using an automated device with high quality control.
The comprehensive nature of the CHMS allowed many risk factors to be considered in the analysis, including BMI and physical activity based on measured data. At the same time, this analysis has some limitations.
Statistical power was somewhat limited because of small sample sizes. Information about medication use was gathered directly from respondents and not verified in medical records.
There is a high prevalence of hypertension in older adults. This condition is undoubtedly iin with increased morbidity and mortality, and Hypertension in older adults Hypertenaion therefore mandatory to treat hypertension, even axults older Hypertension in older adults. However, blood pressure targets Hypertfnsion pharmacologically treated hypertension have not been fully defined. There are specific concerns in the management of hypertension in older persons. There is strong evidence of the benefits of treating hypertension in the elderly. In the elderly, polypathology and polypharmacy, drug-drug interactions, side effects, reduction in compliance, specific conditions like orthostatic hypotension or dysautonomic diseases, and the condition of frailty can all contribute to the creation of complications and challenges in the treatment of many patients. Hypertension affects Improve cognitive speed of all ages and the risk arults developing persistently elevated blood pressure increases xdults age. Hypertension in older adults half of all adults Hypertensikn the United Hypertension in older adults have high blood pressure, and many of them are unaware of it. As arteries tend to stiffen with age, older adults are especially at risk of hypertension and that risk is constantly rising. Internal medicine and endocrinology specialist Dr. Older men and women can take healthy lifestyle steps to lower their blood pressure.
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