Hypertension in Elderly Management/Treatment

Hypertension in elderly is a common problem.
An old patient may come to you with normal appearance and physical signs with slight symptoms of dizziness and occasional headache.
but when you check his blood pressure, you find that it is higher (forexample, > 170 mm of Hg).

Let’s take the following case as an example.

“A 76 year old man visits his physician with the problem of occasional mild headache with no other noticeable symptom; he came to see the doctor because his wife compelled him to do so.

Past Medical History:
 
No history of heart disease, no stroke, no diabetes, no asthma, no TB.

Medications:
Not significant

Allergies:
 
No known drug allergies

Social History:
 
Business Man, smoked during his 20’s for 5 years, wine 2-3 times per week

Family History:
 
Father died of MI, Mother died of Stroke, one brother with coronary artery disease and a sister with stroke and hypertension

Exam
Sitting: BP=180/74 mm Hg; HR=78 bpm
One Minute Standing:
BP=165/72 mm Hg; HR=82 bpm
Three-minute standing
BP=172/70 mm Hg; HR=80 bpm
Repeat sitting BP 20 minutes later:
BP=162/66 mm Hg; HR= 82 bpm

ECG: left ventricular hypertrophy (LVH)

Lab: Electrolytes, BUN, Creatinine, glucose were normal. Urine: no microalbuminuria
Echo showing LVH and diastolic dysfunction

Most Common Cause Of Elderly Hypertension



Arterial stiffness is the most likely underlying mechanism for the elevation in blood pressure noted with aging. Other mechanisms also contribute to elevated blood pressure such as endothelial dysfunction, salt handling difficulties, and decline in baroreceptor sensitivity, Kidney disease etc.

This is not orthostatic hypotension. His sit-to-stand blood pressure change is 8/4 mm Hg, which does not support the diagnosis of OH. The consensus is that a drop of 20 mm Hg in systolic blood pressure or a drop of 10 mm Hg or greater in diastolic blood pressure is needed for a diagnosis of Orthostatic hypotension.

Management

You advice the patient to measure his blood pressure at home and to return for a follow-up visit. He returns with home readings above 155/80 mm Hg and clinical sitting blood pressure of 180/70 mm Hg. His standing pressure was 170/65 mm Hg.

 
BP Classification
SBP
DBP
Life Style
Initial Drug Therapy
Normal
< 120
< 80
Encourage
-           
Prehypertensive
120 - 139
80 - 89
Yes
No antihypertensive Indicated
Stage 1 HTN
140 - 159
90 - 99
Yes
Thiazide Diuretic for most,  may consider ACEI, ARB, BB, CCB or combinations
Stage 2 HTN
> 100
> 160
Yes
Two drug combination for most ( usually thiazide diuretic and ACEI or ARB or BB or CCB
ACEI : ACE Inhibitors ,    ARB: Angiotensin receptor blockers,  BB: Beta blockers,   CCB: Calcium channel blockers



JNC7 recommends starting therapy with both pharmacological and non-pharmacological(eg. Life style modifications) therapy if hypertension is confirmed.

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