Treating systolic hypertension. A Cochrane review conducted more than 10 years ago to assess the effectiveness of treating systolic hypertension in otherwise healthy older patients found that treatment reduced cardiovascular morbidity and mortality by 53 events per 1000 patient-years.12 Several prospective, double-blind, randomized, placebo-controlled studies found that treatment of systolic hypertension in healthy elderly patients reduced the incidence of total mortality (NNT=59), fatal and nonfatal cardiovascular events (NNT=26), and fatal and nonfatal stroke (NNT=79).13
Getting past common barriers to treatment
Despite these findings, many elderly patients with hypertension do not receive adequate treatment, often because of clinicians’ concerns about uncertain parameters and treatment risks. We’ve identified some common barriers and suggested ways to get beyond them.
BARRIER: Unclear parameters, concerns about aggressive Tx
There is little doubt of the value of treating stage 2 systolic hypertension (≥160 mm Hg) in the elderly. Not so for stage 1 systolic hypertension (140-159 mm Hg): A 2004 systematic review of studies evaluating the treatment of elevated systolic pressure in this patient population concluded that evidence for treating stage 1 systolic hypertension was not as strong.14
Observational studies suggesting a link between aggressive blood pressure-lowering and increased mortality in elderly patients have also been a cause for concern among some physicians.15,16 The INDANA meta-analysis, conducted in 1999, reviewed data from patients 80 years of age and older enrolled in antihypertensive trials and found a nonsignificant increase in death rates among patients who received treatment.17
How to respond? Carefully weigh the potential benefits of antihypertensive therapy in view of the overall health, functional status, and risks of side effects for a particular patient. The findings of the INDANA meta-analysis, while not statistically significant, serve as a reminder of the need to individualize treatment.
In the absence of a definitive treatment approach, it is also important to discuss the options with the patient. The authors of the systematic review that evaluated the benefits of treatment for stage 1 systolic hypertension recommended that antihypertensive therapy be based, in part, on patient preference and tolerance of therapy.14
BARRIER: Risks associated with multiple medications
The concurrent use of multiple medications, which is very common in the elderly, can interfere with treatment of hypertension in 2 ways: Some drugs have the potential to cause (or exacerbate) elevated blood pressure. Others may counter the effects of antihypertensive therapy.
Among the drugs that contribute to hypertension are the sympathomimetic agents found in many over-the-counter (OTC) cough and cold preparations in which the mechanism of action is direct vasoconstriction.18 Tricyclic antidepressants, which are commonly used to treat pain syndromes in the elderly, have also been shown to raise both systolic and diastolic pressure.19
On the other hand, nonsteroidal anti-inflammatory drugs (NSAIDs), often used by elderly patients to treat osteoarthritis, may counter the effects of many antihypertensive agents. Both OTC and prescription NSAIDs inhibit cyclo-oxygenase-2 (COX-2) in the kidneys, resulting in a reduction in sodium excretion and an increase in plasma volume.20
How to respond? Take a thorough medication history, including OTC and prescription drugs and supplements, before initiating treatment. Caution patients to avoid NSAIDs, OTC cough and cold preparations, and excessive caffeine, all of which may elevate their blood pressure. Remind patients that any new medication prescribed by another physician may affect their blood pressure, and advise them to maintain a current list of all medications to be reviewed at each visit.
BARRIER: Concerns about side effects
The elderly are more susceptible to orthostatic hypotension than younger patients because of age-related decreases in the baroreflex.21 Estimates suggest that anywhere from 5% to 50% of individuals older than 65 years are affected.21 Orthostatic hypotension, a side effect of many antihypertensive agents, is associated with higher rates of dizziness, syncope, and falls—a particular concern in elderly patients with a history of osteoporosis, pathological fracture, or gait dysfunction (See “Screening for hearing loss, risk of falls”).
How to respond? Before initiating antihypertensive therapy, take your patient’s blood pressure in both a sitting and standing position. Educate the patient and his or her family about the presentation of orthostatic hypotension, and advise the patient to stop taking the new medication and contact you if he or she develops the associated signs and symptoms. Schedule frequent follow-up appointments to closely monitor the effects of antihypertensive therapy, as well.
Stress the importance of lifestyle interventions
JNC 7 recommends several nonpharmacological treatments for all hypertensive patients, regardless of age. These include: