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The general objective of hypertension management for both community-dwelling and nursing home patients is to reduce morbidity and mortality by early diagnosis and treatment with the least-invasive and most cost-effective methods. Classification of hypertension, stratification for CV risks, and management strategies according to JNC 7 guidelines are shown in Table 30–1. Table 30–2 enumerates major risk factors. Little information is available to guide clinicians regarding hypertension management in octogenarians and nursing home residents, typically the frail, older adult group.
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The National Institute for Health and Clinical Excellence (NICE) recommends aiming for a target BP below 140/90 mm Hg in people younger than 80 years of age with treated hypertension, and for a target clinic BP below 150/90 mm Hg in people age 80 years and older with treated hypertension. The American College of Cardiology Foundation and American Heart Association (ACCF/AHA) 2011 Expert Consensus recommends that an achieved SBP of 140–145 mm Hg, if tolerated, is acceptable in octogenarians. In patients with hypertension and chronic kidney disease (CKD) or diabetes mellitus (DM), JNC 7 recommends goal BP of <130/80 mm Hg irrespective of age, a target that may be too aggressive for most older adults.
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The ACCORD-BP trial (age range: 40–79 years) failed to show any reduction in fatal and nonfatal major CV events with lowering SBP to <120 mm Hg, when compared with target SBP <140 mm Hg, in diabetics at high risk for CV events. These results were supported by the INVEST diabetes subgroup analysis, where mean age group was 66 years. In the AASK trial (age 18–70 years), lowering mean arterial pressure (MAP) to a goal of <92 mm Hg, didn’t show any significant difference in all-cause mortality, CV death, or overall CV events, when compared to the usual MAP goal of 102–107 mm Hg, in African Americans with CKD. Consistent with difficulties in finding data for the oldest adults, the ACCORD-BP trial excluded those aged >79 years, whereas AASK trial excluded those aged >70 years. HYVET (Hypertension in the Very Elderly Trial), which targeted adults age >80 years and aimed reduction in BP to <150/80 mm Hg in the active treatment group, showed reduction in incidence of strokes, but a nonsignificant increase in all-cause mortality and CV mortality in the active treatment group compared to placebo. In the INVEST substudy on outcomes of treatment of hypertension in individuals with CAD age >80 years when compared with individuals age <80 years, there was persistence of “J-curve” relationship between lower BP (especially DBP) and increased all-cause mortality, nonfatal MI and nonfatal strokes in individuals age >80 years (Figure 30–2). Keeping in view this data, it is expected that JNC 8 guidelines will have a fresh outlook on this issue.
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Management of hypertension in frail older adults should be tailored while keeping in mind the individual’s functional and cognitive status, and possible side effects of each management plan. The clinical benefit of treating hypertension in older adults appears within a year of treatment. Therefore, treatment of hypertension in older adults with limited life expectancy requires a review of benefits and risks of such therapy.
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Nonpharmacologic Therapy—
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Lifestyle interventions may benefit older adults with hypertension and can include the following:
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Dietary sodium
The USDA recommends reduction in dietary sodium intake to 2.3 g (6 g of sodium chloride) per day for adults 50 years or younger, and <1.5 g for adults >51 years, and those at high risk for vascular diseases. However, restricting sodium in frail elders may worsen or precipitate anorexia, malnutrition, sarcopenia and orthostatic hypotension. The TOHP and TONE trials which demonstrated long-term benefits of dietary salt reduction excluded very old subjects. The strongest evidence for dietary sodium recommendations for hypertension in older adults comes from the TONE trial, where there was clinical benefit to lowering dietary sodium to a mean of 2.3 g daily to adults up to the age of 70 years. There are no data in older adults supporting a 1.5-g sodium restriction.
Diet plan
The Mediterranean diet has been shown to reduce all-cause mortality, and mortality as a result of cancer and CV disease in older adults. The Dietary Approaches to Stop Hypertension (DASH) diet includes whole grain products, fish, poultry, and nuts, with reduction in lean red meat, sweets, added sugars, and sugar-containing beverages. It is rich in potassium, magnesium, calcium, protein, and fiber. The DASH diet has shown reduction in BPs in short-term studies (with up to 8 weeks of follow-up) in middle-aged adults, but lacks long-term follow-up data in older adults.
Alcohol
Heavy alcohol intake (>300 mL/week or 34 g/day) is strongly, significantly, and independently related to elevation in SBP and DBP. It is also associated with higher risk of CV events, strokes, and all-cause mortality compared with occasional drinking. Aging is associated with a number of physiologic changes suggesting increased sensitivity to alcohol, which can additionally lead to increased cognitive impairment, functional decline, and falls in this population. Moderate alcohol consumption (1 standard drink, or 14 grams of pure alcohol, per day) is associated with reduced risk of CV disease. Therefore, the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that those age 65 years and older limit themselves to 1 alcoholic drink per day. However, further reduction may be considered in older adults experiencing cognitive impairment, falls, and functional decline, and for those who take prescription psychotropic medicines.
A standard drink is 12 oz of beer with 5% alcohol, 5 oz of wine with 12% alcohol, or 1.5 oz of hard liquor with 40% alcohol.
Exercise
Increasing physical activity to 30–45 minutes of aerobic activity 4 or more days per week. If this is not attainable, any increase in physical activity is likely to be beneficial.
Weight reduction
An obese older adult has a body mass index (BMI) >30 kg/m2. The TONE trial showed reduction in BP with weight loss through physical exercise and dietary restrictions. However, it excluded individuals >80 years old and those with chronic diseases. Population data in older adults suggest that being underweight poses as great a threat to physical disability as being excessively obese. A 12-year follow-up of mortality data of the weight loss intervention group of TONE trial failed to show any mortality benefit over the non–weight-loss intervention group. Therefore, moderate weight loss should be encouraged in obese older adults, only if consistent with functional and nutritional goals.
Smoking cessation
Older adults should be encouraged to quit smoking, with the assistance of nicotine patches, gums, etc. Bupropion and varenicline may be prescribed while monitoring for adverse effects.
Polypharmacy
Medications that can potentially impair BP control (eg, venlafaxine, NSAIDs) should be stopped if clinically possible, weighing benefits and risks of such treatments.
Dark chocolate
Polyphenol-rich dark chocolate has been shown to lower BP in various studies. Clinical outcome data (eg, stroke reduction) are not available.
Use of nonpharmacologic measures to control hypertension in the nursing home setting may be limited because residents are often impaired in their activities of daily living, and unable to participate in moderate exercise. Also, weight loss is a problem rather than a goal for most nursing home residents. If their diet is restricted in salt or animal and dairy fat, they may lose weight, strength, muscle mass, bone density and essential nutrients.
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Pharmacologic therapy—
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Antihypertensive medication improves CV and cerebrovascular outcomes in older adults with BP ≥160/90 mm Hg. The absolute benefit of hypertension treatment tends to be greater in men, in patients age 70 years or older, in those with previous CV complications, and in the presence of wider PP. The key to achieving maximal benefit and minimal risk in older adults is to “start low and go slow.” Lower initial doses of antihypertensives minimize the risk of postural and postprandial hypotension as well as ischemic symptoms, especially in frail older adults. Choice of initial antihypertensive agent thus depends on comorbidities and side effects. If the baseline BP is more than 20/10 mm Hg above goal or optimal reduction in BP is not achieved with one agent, a second agent can be added while weighing benefits and risks of such therapy on individual basis.
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Special attention should be paid to frail patients and octogenarians when initiating a new antihypertensive medication. They should be seen frequently, with updated medical history and assessment for any new adverse effects, especially dizziness or falls. Standing BP should always be checked to identify excessive orthostatic decline. Although BP values below which vital organ perfusion is impaired in octogenarians are unknown, SBP <130 and DBP <65 mm Hg should be avoided.
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Route of administration may be an issue in nursing home residents with dysphagia and those who are unwilling to take pills. A low dose clonidine or nitroglycerin patch may be beneficial in BP management in these situations, while monitoring for potential adverse effects, particularly from clonidine. Because orthostatic and postprandial hypotension may contribute to the risk of falling, it may be appropriate to titrate antihypertensives based on readings obtained in standing posture. Also, BP tends to be highest before breakfast in the nursing home resident, and falls after breakfast. So titration of antihypertensives should be done based on multiple readings during various times of the day.
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Table 30–2 summarizes data on antihypertensive agents commonly used in older patients.
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Thiazide and related diuretics are the preferred first-line treatment in older adults and have proved particularly effective in blacks and in salt-sensitive hypertensive patients. Diuretics have been shown to lower cerebrovascular and CV morbidity and mortality, decrease left ventricular mass, and prevent heart failure. Diuretics are a reasonable choice for diabetics based on findings of ALLHAT trial, which indicated that despite the slightly higher incidence of diabetes in the thiazide treatment group of the trial, there was no significant difference in clinical events in diabetic patients assigned to either diuretic, angiotensin-converting enzyme (ACE) inhibitor or calcium channel blocker regimen. In low doses, thiazides have advantages of low cost and possible preservation of bone mineral density in older women. Side effects of thiazides include increased insulin resistance, hypokalemia, hypomagnesemia, hyponatremia, hypercalcemia, orthostatic hypotension, urinary incontinence, sexual dysfunction, and exacerbation of gout. Thiazides may be ineffective in patients with a creatinine clearance of <30 mL/min and can be replaced by loop diuretics (eg, furosemide) when a diuretic agent is necessary.
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Angiotensin-converting enzyme inhibitors & receptor blockers—
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Because of well-known renoprotective effects of ACE inhibitors and ACE receptor blockers (ARBs) in type 2 diabetes, current guidelines suggest using one of these agents as first-line drugs in older adults with both diabetes and hypertension. ACE inhibitors also appear to improve vascular outcomes in high-risk patients, including diabetics and those with established vascular disease. The LIFE study showed reduced CV mortality and incidence of stroke in individuals with ISH when treated with losartan (ARB) compared to atenolol (β-blocker). ARBs are also used when there is intolerance to ACE inhibitors (because of cough). There is no long-term data available on aliskiren, which is the only available drug in the class of direct renin inhibitors.
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Older adults are less responsive than younger adults to β blockers and are less likely to have BP control with β-blocker as a sole agent. In addition, compared with diuretics, β blockers may offer less reduction in cerebrovascular and CV events in older antihypertensive patients. However, they are effective in older adults with CAD for secondary prevention of MI, for rate control with exercise in atrial fibrillation, and for reducing mortality and hospital readmission in patients with left ventricular systolic dysfunction.
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Calcium channel blockers—
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Nitrendipine (not currently available in United States), a dihydropyridine calcium channel blocker (CCB) related to amlodipine and felodipine, significantly decreases the risk of cerebrovascular morbidity and mortality. Dihydropyridine CCBs are available in the United States and include nifedipine, amlodipine, and felodipine. The ACCOMPLISH trial showed that amlodipine-based regimen may be more effective than a thiazide-based regimen in reducing CV events in high-risk patients, including diabetics, and is a good alternative choice for diabetics. However, CCBs are a heterogeneous group, and the benefits of one class of CCBs may not necessarily be extrapolated to another. Diltiazem and verapamil, two commonly used nondihydropyridine CCBs, have negative inotropic and chronotropic effects on left ventricular systolic function compared with amlodipine or felodipine. They may be used as adjunctive agents in patients with renal parenchymal disease and resistant hypertension but should be used with caution in systolic dysfunction.
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Low doses of selective α1-adrenergic antagonists (eg, terazosin, doxazosin) may be useful for managing hypertension in the setting of benign prostatic hypertrophy. Their major side effects are orthostatic hypotension, reflex tachycardia, and headache. The findings of slightly increased risk of stroke and CV events and a doubled risk of CHF in the doxazosin arm compared with chlorthalidone in the ALLHAT trial, suggest that the α-antagonists should not be chosen as a first-line antihypertensive agent.
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Aldosterone antagonists—
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Aldosterone antagonists (spironolactone and eplerenone) are often beneficial in resistant hypertension due to primary hyperaldosteronism and OSA, including in African Americans.
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JNC 7 recommends that combination drug therapy be initiated for stage II hypertension (SBP ≥160 or DBP ≥100 mm Hg). In the ALLHAT trial, approximately half of the high-risk older adults with hypertension required combination therapy. Participants on lisinopril and amlodipine were more likely to require combination therapy than those assigned chlorthalidone. This finding supports the JNC recommendation that a diuretic be a primary choice for an antihypertensive agent.
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Combination drugs potentiate antihypertensive activity by acting at different sites simultaneously. Formulations that combine low doses of different classes of drugs improve BP control while minimizing the adverse effects of either drug. These drugs may, in some cases, be priced competitively with either of the combination agents, reducing the patient’s out-of-pocket expenses as well. Lower cost, increased ease of compliance, and potential for fewer side effects make combination drugs attractive for use in older adults once the need for more than one agent is established.
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Diabetes & Hypertension
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Type 2 diabetes is 2.5 times more likely to develop in individuals with preexisting hypertension compared with those with normal BP and greatly increases CV risk. Treatment options are discussed in individual drug sections.
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Hypertension in African Americans
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The first-line agent in African Americans with uncomplicated hypertension should be a thiazide diuretic. CCBs effectively lower BP and decrease CV events, especially stroke in this population, and can be a good alternative or second choice. Renin-angiotensin-aldosterone system (RAAS) inhibitors appear less effective than other drug classes in decreasing BP in older African Americans, unless combined with diuretics or CCB.
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Hypertension & Chronic Kidney Disease
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Treatment with an ACE inhibitor or ARB is recommended in presence of proteinuria >300 mg/day or concomitant history of heart failure. However, the AASK trial failed to demonstrate any reduction in CV outcomes with β blocker versus ACE inhibitor versus amlodipine CCB regimen in treatment of hypertension in African American patients with CKD.
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Hypertension & Heart Failure
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Older adults with hypertension and systolic heart failure (HF) should be treated with a diuretic, β-blocker, ACE inhibitor, and aldosterone antagonist in absence of hyperkalemia or significant renal dysfunction. If a patient cannot tolerate ACE inhibitor, an ARB should be used. Older African American patients with hypertension and HF may also benefit from combination of hydralazine and isosorbide dinitrate. Hypertension and asymptomatic left ventricle dysfunction should be treated with β-blocker and ACE inhibitor. If HF is refractory to conventional therapy, work-up for renal artery stenosis should be pursued as renal revascularization may improve HF in hypertensive patients.
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Diastolic HF is very common in the older adults. Fluid retention should be adequately treated with loop diuretics, hypertension should be controlled, and comorbidities should be treated. No specific drug class demonstrates superior clinical outcomes at this time.
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Resistant Hypertension
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Hypertension is considered resistant if BP cannot be reduced to goal with an appropriate triple-drug regimen, including a diuretic (plus ACE inhibitor, CCB, β-blocker, or ARB) and if each of the 3 drugs is at or near maximum recommended doses. With ISH in older adults, resistant hypertension is defined as the inability to lower systolic BP to <160 mm Hg with a similar regimen.
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The common causes of resistant hypertension include patient nonadherence to the prescribed medications and diet, a suboptimal medication regimen, drug interaction, pseudotolerance (salt, water retention), and office hypertension. Secondary hypertension and pseudohypertension should also be considered.
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In hypertensive patients with OSA who are overweight, the cornerstone of treatment is weight loss, which improves sleep efficiency and oxygenation and lowers BP. In the absence of dramatic reductions in etiologic factors for OSA, these patients generally require lifetime treatment with continuous positive airway pressure to reduce the number of hypoxemic events. Addition of the mineralocorticoid-receptor antagonist spironolactone to conventional antihypertensive-drug regimens has been shown to reduce the severity of OSA and to lower BP in patients with OSA and resistant hypertension.
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A patient’s adherence to dietary salt moderation can be estimated by obtaining a 24-hour urine collection for sodium. If the patient’s hypertension remains resistant, other medications can be added to the triple therapy. Clonidine in tablet form or by transdermal patch, or another centrally acting sympatholytic agent, can be considered in low doses to avoid side effects of sedation and orthostatic hypotension. Minoxidil, reserpine, and hydralazine are used cautiously because of their high rates of side effects in older patients.
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