Hypertension in the elderly

Abstract

Hypertension is widely recognised as an important modifiable risk factor for vascular disease in old age. Acute myocardial infarction and stroke are responsible for 50-60% of deaths in the over 65s in countries in the developed world. 1 Vascular disease is also the leading cause of major disability in the elderly, 2 and an important contributor to cognitive decline. 3 Randomised controlled trials (including patients up to 85 years of age) have shown that antihypertensive drug treatment in the elderly reduces the risk of both fatal and non-fatal stroke and of deaths due to myocardial infarction and heart failure. 4 The strength of the evidence is overwhelming. How well are we doing at putting this research evidence into clinical practice? Published in this Journal issue is a paper by De Backer et al 1 that gives some answers to this question. They performed a cross-sectional study of elderly people in Belgium between 1994 and 1996. Approximately one-quarter of all elderly subjects were taking antihypertensive drugs. In general, blood pressure (BP) control in those treated for hypertension was good, with twothirds having satisfactory levels, even although the majority of patients were taking a single antihypertensive agent. This contrasts with the WHO-WHL hypertension management audit project where less than one-third of middle-aged subjects treated for hypertension were found to have good BP control. 5 It may be easier to control BP in elderly hypertensives than in younger patients. This is likely to be at least partly a survivorship effect, as poor BP control is associated with increased mortality. 6 The treatment regimens used in the De Backer study were conservative with the commonest drugs being diuretics, followed by beta-blockers, then calcium channel blockers. These groups of drugs have all been shown to reduce vascular events in elderly hypertensives. 4,7 In the absence of specific contraindications, different agents seem to be tolerated equally well in elderly patients; between 10 and 15% will have an adverse reaction requiring a change of drug. 8 Thiazides are of proven value and are cheap. Fifteen years ago they were used in more than half of the elderly hypertensives who received Correspondence: Professor David J Stott drug treatment. 8 Since then there has been a gradual trend to the use of newer (and more expensive) agents, despite consistent advice from most authorities that thiazides should remain as a first choice.Raised BP (defined as systolic у160 and/or diastolic у95 mm Hg) was found in approximately onequarter of screenees in the De Backer study. 1 Older studies have reported between 35 and 50% of the over-65s with elevated BP on a single screening visit. 9 Therefore it is tempting to believe that improvements are being made in the detection of raised BP in elderly people. Of course not all patients with elevated BP at a single visit will have sustained hypertension; if recordings are repeated over several months many subjects will be found to be normotensive. Therefore the above figures will...

Blood pressure and aging

“…5,23 There is evidence that this widespread use is impacting on population blood pressure levels. 24 Starr's article confirms that antihypertensive use is associated with prolonged reductions in blood pressure in the elderly. 20 Therefore there are many different factors that influence blood pressure changes into old age.…”