High blood pressure in the elderly person, providing some light in the dark

High blood pressure (BP) is the most prevalent chronic pathology in the geriatric population and has a great influence on the presence of cardiovascular disease (CVA, ischemic heart disease and heart failure), all of which cause mortality and especially disability. The prevalence of ETS is approximately 65%, mainly of the systolic type, with a degree of control in the community of 30%, however in an institutionalized population with high fragility it is usually higher than 60%.

The reduction of blood pressure figures in the elderly has been shown to reduce the incidence of cardiovascular morbidity and mortality, which is more related to the reduction achieved than to the medicines used. Likewise, very strict control of blood pressure figures can lead to episodes of orthostatic hypotension, syncopal episodes with cerebrovascular failure, and falls, greatly affecting the quality of life of patients. Diastolic blood pressure figures below 65 mm Hg also have a great influence on the presence of ischemic cardiopathy, especially in adults, although in the elderly the high prevalence of silent coronary arteriosclerosis must be taken into account.

In the elderly, the changes of aging itself influence with greater arterial rigidity, accumulated endothelial dysfunction, as well as alterations in the autonomic regulation mainly of the baroreceptors. Previously known hypertension should be considered differently, detecting the affectation of target organs and previous CV events, as opposed to the elderly who become hypertensive with a short life expectancy, since studies require 5 years of follow-up to achieve their objectives.

The recommendations of the European Society of Hypertension and Cardiology (1) were updated in July 2013, including the conclusions of the HYVET study (2008) in a population with low cardiovascular involvement, low prevalence of diabetes and excluding the presence of orthostatic hypotension.

 However, certain questions arise that are not entirely clear;

Should stage 1 hypertensives (systolic TA 140-159 mm Hg and diastolic TA 90-99 mm Hg) be treated?

In studies of hypertension in the elderly, patients recruited have blood pressure figures above 160 mm Hg, so this question is not fully clarified, especially in those over 80 years of age; in elderly people under 80 years of age with good functional status, treatment should be initiated.

 What should be the target blood pressure figures?

There are studies that show that optimal systolic blood pressure levels in people over 80 (2) in the community, especially those with multiple diseases, can increase mortality. In a study where the influence of fragility is assessed(3), measuring it through the speed of walking, it is shown that the most fragile with controlled blood pressure levels have less survival than the most robust with high tensions. Possibly frail elderly or geriatric patients require a certain threshold of blood pressure to maintain adequate organ perfusion, so attempting to achieve low blood pressure figures, especially in diabetic or chronic renal disease patients, may jeopardize the safety of the intervention.

What treatment can be chosen(4)?

Studies have been carried out especially with thiazide diuretics, beta-blockers, which in the very elderly can increase urinary incontinence, prostate symptoms, and falls. Loop diuretics as a first line in monotherapy, are specified in the STOPP criteria and thiazide diuretics if the creatinine clearance is less than 60 ml/min are no longer effective. For all these reasons, calcium antagonists or ACE inhibitors may be more suitable than ARA II since their superior cardiac protection has not been demonstrated and they are indicated if they are intolerant to ACE inhibitors. It should be started with doses lower than those recommended for adults (50%), and with a more gradual titration in weeks or months, assessing their tolerance. Diuretics and ACE inhibitors are recommended for an ion and renal function control at two weeks and in ACE inhibitors also at 6 months.

At least in these expert recommendations, for the first time, different variables are included to be considered in decision making, not only the age aspect, but also the functional level, comorbidity, life expectancy, in order to be able to individualise the treatments according to the integral assessment of the elderly person.

"Doubt is the water that irrigates the tree of intelligence.

(1) 2013 ESH/ESC Guidelines for themanagement of arterial hypertension
(2) Relationship between blood pressure and mortality at 4 years of follow-up in a cohort of individuals over 80 years old (www.elsevier.es/medicinaclinica)
(3) Rethinking the Association of High Blood Pressure With Mortality in Elderly Adults (ARCH INTERN MED/VOL 172 (NO. 15), AUG 13/27, 2012 WWW.ARCHINTERNMED.COM)
(4) When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal (Journal of Hypertension 2009, 27:923-934)