MORE ON AGE MANAGEMENT OF HYPERTENSION

Bistok Sihombing, Dina Aprilia, Arianto Purba, Faisal Sinurat

Division of Geriatric Medicine - Department of Medicine

FK USU / Dr Haji Adam Malik

PRELIMINARY

Along with the increasing age of the chronic diseases is also increasing,

so the elderly more in need of drug therapy for

management of various illnesses suffered. Hypertension is a disease

the prevalence increases with age. Approximately 90% of adult age

with normal blood pressure will develop into hypertension in the elderly. 1

Hypertension in the elderly have some specificity, generally accompanied

with more severe risk factors, often accompanied by disease - another disease that

affect the handling of hypertension such as drug dose, the selection of drugs, side effects

or complications due to treatment more often, there is a target organ complications,

less treatment compliance is often not achieve treatment targets and others - others.

All of this makes the elderly hypertension classified as cardiovascular risk

high or very high. Therefore, treatment of hypertension in the elderly

require much greater attention. 2

Many doctors do not treat hypertension in the elderly until optimal

(Reaching the target of less than 150/90 mmHg) in view of fears of the effect

treatment side greater than the manfaatnya.Selain there is also

several other factors that need to be considered, namely the factors influencing

elderly patient's response to anti-hypertensive therapy, such as atherosclerosis, changes

Cardiovascular due to degenerative processes, reduced baroreflex response and others. 3

Systolic blood pressure (TDS) will continue to increase along with the increase

age, but the increase in Diastolic Blood Pressure (TDD) with age

only occur until about age 55, and then decreased because of

the process of arterial stiffness due to atherosclerosis. In the age group of 60 years,

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only 2/3 of hypertensive patients suffering from isolated systolic hypertension (HST), while

the group 75 years more than three-fourths of patients suffering from HST. 3

Provision of antihypertensive drugs in elderly people with high TDS or TDD

have shown efficacy in reducing morbidity and mortality.

From the results of the last study, HYVET (2008), in patients age population is very

Further over the age of 80 years, the treatment of hypertension successfully reduced

morbidity and mortality. 3

II. EPIDEMIOLOGY

In the years 1988 - 1991 National Health and Nutrition Examination Survey

found the prevalence of hypertension in the age group 65-74 years as follows:

an overall prevalence of 49.6% for stage I hypertension (BP 140-159 / 90-99 mmHg);

18.2% for stage II hypertension (BP 160-179 / 100-109 mmHg), and 6.5%

Third degree hypertension (BP> 180 /> 110 mmHg mmHg). Systolic Hypertension Prevalence

Isolated (HST) is approximately consecutive -turut: 7%; 11%; 18% and 25% in the group

ages 60-69, 70-79, 80-89, and over 90 years. HST is more common in

women than men - men. 4

In 2010 the Indonesian population over the age of 60 years

is expected to be increased by 400%, far greater than

with a predicted population of infants (under age five). The prevalence of hypertension by age

> 60 years is very high, and when accompanied by a risk factor for cardiovascular disease other

(Eg, obesity, left ventricular hypertrophy, lack of physical activity / exercise,

hyperlipidemia, chronic kidney disease, and diabetes) would cause a risk

morbidity and mortality. 3

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Figure 1. The composition of the elderly population in Indonesia in 2012 (source:
Ministry of Health, Indonesia Health Profile 2012.

Figure 1 above shows the composition of the elderly population in Indonesia

2012. It seems the proportion of elderly population in 2012 amounted to 7.59%.

The population of elderly women (10,046,073 inhabitants or 54%) more than

the elderly population of men (8,538,832 people or 46%). 5

Since 2000, the percentage of elderly population exceeds 7%, which means

Indonesia began to enter into the group of countries the old structure (aging population).

Their aging population structure is a reflection of the higher age

Life expectancy (UHH). The high life expectancy is one indicator of success

the achievement of national development, especially in the health sector. 5

Figure 2. Development of the proportion of elderly population in Indonesia in 1980-2020 (Source: CBS, 2012)

From the results of the National Basic Health Research (RISKESDAS) 2007

the prevalence of hypertension in Indonesia amounted to 31.7%, which increased more

much so that over 55 exceeds 50%. In developed countries like America

States the prevalence of hypertension in over 65 years of age is 72%. On research

Framingham (Framingham Heart Study) mentioned that the group

have Optimal blood pressure (<120/80 mmHg), normal (120-129 / 80-84 mmHg)

nor high normal (130-139 / 85-89 mmHg) after observation for

four years, it was found that there is a progressive increase for experience

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hypertension at the age> 65 years (16, 26, and 50% each - each). The thing that

similar to that of younger age groups, but with the level of

lower progression. In the age group 55 to 65 years with pressure

Normal blood, approximately 90% will be stage I hypertension (BP 140-159 / 90-99 mmHg)

and about 40% will be stage II hypertension (BP ≥160 / ≥100 mmHg). 2.6

Table 1. Prevalence of Hypertension in Indonesia from 2007 RISKESDAS

Age group prevalence

18 -24 12.2
25 -34 19.0
35 -44 29.9
45 -54 42.4
55 -64 53.7
65-74 63.5
> 75 67.3
Average 31.7

Quoted from Science Textbook In the disease, Issue VI 2014 2

Table 2 below shows the 10 most diseases suffered by

the elderly in 2013. It seems kind of disease that dominates is

class of non-communicable diseases, chronic and degenerative diseases, especially type

cardiovascular disease. 5

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Table 2. 10 Most Diseases in the Elderly in 2013 5

III. DEFINITION

In the management of hypertension recommendations issued by the

Seventh of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment

of High Blood Pressure (JNC VII) in 2003, the World Health Organization / International

Society of Hipertension (WHO-ISH) 1999, the British Hypertension Society, 2006,

European Society of Hypertension / European Society of Cardiology (ESH / ESC) 2007,

the definition of hypertension is similar for all age groups over 18 years. treatment also

not based on age classification, but based on the level of blood pressure

and the presence of cardiovascular risk in patients. 3

Table 3. Definition of JNC Hypertension - 7

Systolic BP Diastolic BP
Classification
(mmHg) (mmHg)

Normal <120 and <80

Prehypertension 120-139 or 80-90
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension ≥160 or 100
Isolated Systoloc Hypertension ≥ 140 and ≤ 90

Quoted from: JNC-7, 2003 7

Isolated Systolic Hypertension (HST) defined as blood pressure

systolic ≥ 140 mmHg in diastolic blood pressure of ≤90 mm Hg. The increase in pressure

systolic and diastolic blood pressure reduction usually occurs over the age of 60

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year. This is in line with the reduced elasticity of the large blood vessels (aorta) and

the process of atherosclerosis. HST found in approximately 60-75% of cases of hypertension in

elderly with increased risk 2-4 fold for the occurrence of myocardial infarction,

left ventricular hypertrophy, impaired renal function, stroke and cardiovascular mortality.

Cardiovascular complications is directly proportional to the increase in systolic blood pressure

(TDS) and pulse pressure and inversely proportional to the decrease in blood pressure

Diastolic (TDD). The higher the systolic blood pressure or pulse pressure, the more

severe risk of cardiovascular complications. Increased pulse pressure in the elderly

with HST related to the magnitude of damage that occurs in the target organ, ie

heart, brain and kidneys. Besides a decrease in diastolic blood pressure (TDD) is too

low-risk, reducing blood flow to the coronary arteries. From SHEP study

found that an increase in cardiovascular events occur when BP <60 mmHg.

In the other study found the increase in the incidence of stroke in diastolic blood pressure

(TDD) <65 mmHg. 2,3,6

According to the Law of the Republic of Indonesia Number 13 of 1998 on

Elderly welfare, is the Elderly (elderly) is someone

who have reached the age of 60 years and above. The success of development in various

field mainly causes an increase in health expectancy

Population living world, including Indonesia. But behind the success of improvement

UHH tucked challenge to watch out, that in the future Indonesia will

facing the brunt of three (triple burden) that in addition to increasing the birth rate

and the burden of disease (infectious and contagious tidk), will also be an increase in Numbers

Dependent burden the productive age group population to the age group of non

productive. In terms of health, the elderly group will experience

decline in health status either naturally or as a result of the disease. Therefore

it is in line with the increasing number of elderly people then since

Now we have to prepare and merencanakanberbagai health program

aimed at the elderly. 5

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IV. MORE ON HYPERTENSION Pathophysiology AGE

Unlike the younger age group, patients with hypertension at the age of

more frequent reduction of arterial elasticity or increased rigidity

artery ( elastin collagen tissue replaces the elastic lamina layers in vessel

aorta) experienced during the aging process and the process sclerosis mainly on

great arteries, resulting in a higher systolic blood pressure and the pressure

lower diastolic or the increase of pulse pressure (pulse pressure). This matter

causing a condition known as isolated systolic hypertension, which

handling is more difficult than the usual essential hypertension. 2,3,8

endothelial dysfunction is one of the important contributors pressure meingkatnya

blood in the elderly. Both mechanical injury due to inflammation of the arteries aging

lead to decreased availability of the vasodilator nitric oxide (Nitric oxide; NO),

which causes an imbalance between vasodilators (such as NO) by

vasokontriktor (such as endothelin). 8

Additionally the elderly often experience dysregulation of the nervous system

autonomous which can cause orthostatic hypotension namely menurunanya blood pressure

systolic> 20 mmHg and / or diastolic blood pressure> 10 mmHg after standing of

a seated position for three minutes. Orthostatic hypotension is a risk factor for

the occurrence of falls (falls), syncope (syncope) and the incidence of cardiovascular events.

Autonomic dysregulation can also cause orthostatic hypertension, namely to increase

systolic blood pressure at the time of change in posture into a standing position, and

a risk factor for left ventricular hypertrophy (LVH), arterial disease

Coronary (CAD), and other cerebrovascular diseases are asymptomatic (silent

cerebrovascular disease). Up to now there is no consensus menjelakan

regarding the definition of orthostatic hypertension, although some studies have

using the definition about 20 mm Hg increase in systolic blood pressure

changes into a standing position. 8

Other complications such as microvascular damage to the kidneys has also become one

one cause of chronic kidney disease (CKD), which result in reduced tubular function

kidney in regulating the electrolyte balance of sodium and potassium. Kidney function

decreases progressively in the elderly may occur also by the process glomerulo-

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sclerosis and fibrosis-intestinal cause a rise in blood pressure through

mechanisms increase intracellular sodium, reduced sodium-calcium ion exchange, and

blood volume expansion. 2

The increase in blood pressure due to the need of secondary causes

considered, such as renal artery stenosis caused by lesions

atherosclerosis, apnoe sleep apnea (OSA), increased cardiac output (Cardiac

Output) due to anemia, aortic insufficiency, arteriovenous fistula, primary aldosteronism,

Paget's disease and thyrotoxicosis. The cause another increase in blood pressure is

excessive lifestyle, drinking alcohol, smoking, caffeine consumption,

drugs NSAIDs (Non-steroidal anti-inflammatory), the use of steroids, hormones, drugs,

less intake of calcium, vitamin D and vitamin C. 2.6

HST influence on cardiovascular morbidity and mortality

In old age, the treatment is not only measured by success

drop in blood pressure on cardiovascular morbidity and mortality, but also by

a variety of things, including the effect on stroke, dementia prevention or reduction function

cognitive, as well as the effect of diabetes, and body mass index (BMI) or obesity. 3

stroke

Hypertension is a major stroke risk factors that have a high potential

to be modified. Any increase 7 mmHg TDD can increase the relative risk

of stroke by 100%. Preventive therapy for meurunkan morbidity

and stroke mortality by way of controlling hypertension indicates success

meaningful. Hypertension treatment regimen that can sustain a decline TDD

by 5-6 mmHg in the long term may reduce risk factors by 35

- 40%. 3

Cognitive Function and Dementia

Cognitive decline marked by forgetting something new, but still

can perform basic daily activities - day. In the last decade, many researchers

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who made observations of the relationship between hypertension and dementia, including

including Alzheimer's disease. 3

Although the study / research Hypertension in the Very Elderly Trial - Cognitive

(HYVET-COG) found no significant difference between groups

antihypertensives and non-hypertensive group on dementia and decrease the function

cognitive, concluded that it shall be underlined is that the administration of anti

hypertension not Improve the risk of dementia or cognitive impairment. case

This is important, because some of the opinions that circulate believe that treatment

hypertension will lead to a decrease in cerebral blood flow, which in turn will

cause dementia or cognitive impairment. 3.9

Diabetes Mellitus (DM)

Patients with diabetes have a greater cardiovascular risk

compared with no diabetes. Based on research / studies reported SHEP

the first time in 1996, and the Syst-Eur 1999 in elderly patients with DM,

found that treatment of diuretic or a calcium antagonist has the effect

the same blood pressure reduction. When compared to non-DM patients,

patients with DM had a reduction in morbidity and mortality is greater.

This is important given the assumption that the only ACE inhibitor or ARB very

is recommended in patients with DM. The results of these two studies emphasize the importance of

pencapaiaan blood pressure control in the elderly. 3

Effect of Body Mass Index (BMI) on Hypertension Prognosis Elderly

SHEP study the use of diuretics, resulting in survival parameters

and better clinical events in which includes obesity, than

have a normal BMI. It has long been known that patients with hypertension who are obese

have a better prognosis than those skinny. One of

penjelasannnya is that in hypertensive patients who are obese, an increase in pressure

Blood is mainly caused by the increased plasma volume, whereas in patients

hypertension who are not overweight caused by an increase in the sympathetic system and the system

renin angiotensin. In addition, increase in blood pressure in older people with obesity,

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also associated with increased activity of leptin and insulin resistance.

So that weight control is an important component of the treatment of non-

Pharmacologic. 3

V. Diagnosis

Diagnosis of hypertension in the elderly together with other hypertension diagnosis.

Diagnosis of hypertension is based on the measurement of blood pressure is good and

right and do at least three (3) times the measurement of blood pressure

different, and performed at more than two (2) visits. Measurement of blood pressure

carried out at least two (2) times each visit, after the patient is seated

Comfortable at least five (5) minutes with backrest, foot located at

floor, arms placed on the armrest with a horizontal position and the position of the cuff

parallel to the location of the heart. Measurements of blood pressure in elderly kelimpok

should also be done in a standing position from a sitting position after 1 to

3 minutes. This was done to evaluate the presence of hypotension or hypertension

postural. 15

Blood Pressure Measurement

Blood pressure measurements accurately is necessary, both at the time

diagnosis of hypertension as well as to evaluate the results of treatment.

Accurate measurement of blood pressure is considered to represent the true value in patients

advanced age is often a challenge, especially due to the physiology

aging (degenerative) happens. 3, 16

Blood pressure measurements are not accurate can also occur due to factors

pseudo-hypertension, which occurs when a blood pressure cuff fails to compress

brachial arteries rigid and hardened by the process of calcification. 3

Barorefkleks decreasing response with age can lead to hypotension

orthostatic. Therefore, it is often found that blood pressure dropped

Excessive in a standing position, after a meal or after a long day. With

Thus blood pressure measurement should be performed in a sitting position and the position

stand up. 3

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 Recommendations Measurement of Blood Pressure Canadian Hypertension Education

Program (CHEP, 2009) 3:

• Measurements should be done with spigmomanometer

• Use the appropriate cuff, bladder width of approximately 40% of arm circumference, length

bladders around 80-100% arm circumference.

• The lower limit of the cuff about 3 cm above the elbow fold and bladder should be laid

such that the brachial artery at the center - the middle of the bladder.

• Before taking measurements, the patient must sit resting comfortably on

backed chair for at least 5 minutes.

• Measurements were performed on a bare arm. Arm placed so that

so the antecubital fossa parallel to the heart.

• When the examination is done, the patient should not be talking, foot / leg should not be

crossed.

• Develop cuff up to 30 mmHg higher than the pressure when the arterial pulsation

The radial disappeared.

• Reduce pressure cuff at a rate of 2 mmHg every heartbeat.

• systolic value • when the beating was clearly heard first (phase I Korotkof)

• Diastolic value • when the beating was not heard from again (phase V Korotkof)

• Continue auscultation of up to 10 mmHg under phase V Korotkof

• When the beating of phase V Korotkof still sounds up to 0 mmHg, then the

diastolic is considered value "Muffling Sound" ( Phase IV Korotkof)

• Compare with the heartbeat frequency

• Minimum measurement performed three times at the same position. Leave a gap of at least

one minute each measurement is made. The first measurement is ignored, then

taken - average of two subsequent measurements.

• Blood pressure upon standing should also be measured after the patient is standing two minutes,

similarly when patients have complaints of orthostatic hypotension.

• Blood pressure while sitting used to establish diagnosis and management

hypertension.

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 • Blood pressure upon standing is used for postural hypotension, which when detected

can alter the treatment of hypertension were selected.

• Measurement of blood pressure in both arms should be done at minimal

one visit. When one arm consistently shows the pressure

blood is higher, then the sleeve should be used as a benchmark

for the measurement and interpretation of blood pressure.

In addition to measuring blood pressure in the clinic (office), the measurement of blood pressure as well

can be done at home (out of office) either by means of Home Blood Pressure

Measurement (HBPM) nor Ambulatory Blood Pressure Measurement (ABPM).

The main advantage of HBPM and ABPM measurement is blood pressure measurement

do not be in a medical atmosphere such as in a clinic or hospital, so the atmosphere

become more comfortable and Santi for patients. 16

Ambulatoris blood pressure monitoring (ABPM; Ambulatory bood Pressure

monitoring) can be useful in the documentation "white coat hypertension" and to

verify the symptoms of hypotension in patients - patients who received anti-hypertensive therapy.

A study found that monitoring blood pressure ambulatoris is

a better predictor of cardiovascular risk than measurements

Conventional blood pressure in the elderly population with Systolic Hypertension

Isolated (HST). The option to do HBPM or ABPM based on

tool availability, cost and ksediaan patient. HBPM generally carried out in the center

primary serviceability, while ABPM performed at a service center specialist 3, 16

Table 4. Definition of hypertension based on clinic blood pressure measurement and

measurement of blood pressure at home (outside the clinic) 16

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Table 5. Clinical indications for HBPM and ABPM 16

Clinical symptoms

Most patients with hypertension in the elderly have no symptoms

(Asymptomatic). Symptoms are usually seen in hypertension include: dizziness,

palpitations (heart palpitations), or headaches. Skit head in the morning, especially

The occipital region is characteristic of Stage II hypertension. damage to the target

organs such as stroke, congestive heart disease, or kidney failure may be the

early signs. 8

hospital sheet

History of the disease and course of the disease the patient should be directed in accordance with

the possibility of secondary causes of hypertension, can include weight gain,

polyuria, polidipsi, muscle weakness, headache previous history, palpitations,

diaphoresis (excessive sweating), weight loss, anxiety, and sleep history

(For example: sleep more during the day, snoring is a strong pain in the head

early in the morning). 8

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 Symptoms and signs of suspected abnormalities in organ recipients include:

headache, weakness or temporary blindness, claudication, chest pain, and shortness

breath. Comorbid illnesses such as diabetes mellitus, coronary heart disease, failed

heart disease, chronic pulmonary obstructive disease (PPOM), gout, and sexual dysfunction

is an important finding, because it will be linked to the stratification of risk factors

coronary and choice of initial treatment (early). 8

Drugs of a history of drug use, including the use of anti-hypertensive drugs

previously, the counter drugs used such as NSAIDs and flu drugs and drug types

herbs need to be asked. Daily habit - today and lifestyle during this time include

smoking, drinking alcohol, use of drugs (narcotics), physical exercise

regular, and the degree of daily physical activity should be assessed. History diet

such as high-salt diet (which can raise blood pressure), consumption of fat

(Increase cardiovascular risk), and alcohol (which when consumed

in excessive amounts can trigger a rise in blood pressure) is very important for

ask the patient or patient's family history when done. 8

Physical examination

Physical examination aims to confirm hypertension and for

to identify possible causes of secondary hypertension. Check up result

Physical directed to the target organ disorders such as vascular changes ophthalmologic

on funduskopi, carotid bruit in the widening of veins in the neck, the sound of a third heart sound

and fourth, ronkhi wet lung, and the weakening of peripheral arterial pulsation). Examination

cognitive function (such as the Mini Mental State Examination (MMSE), the Montreal Cognitive

Assessment, or St. Louis University Mental Status Examination) is helpful

in detecting impaired cognitive function in elderly patients with

hypertension. The cause of secondary hypertension including renal bruit (stenosis

renal artery); moon face, buffalo hump, and abdominal striae (in Cushing's syndrome);

tremors, hyperreflexia, and tachycardia (at thyrotoksikosis) should be checked secaa

carefully. 2,3,8

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Laboratory tests and other investigations

Laboratory tests are intended to determine whether there is a factor

Additional risks, look for the possibility of secondary hypertension and target organ damage.

Complete blood count, kidney function tests, uric acid, electrolytes, panel

metabolic, lipid profile, fasting blood sugar levels, Thyroid function tests (thyroid stimulating

hormone; TSH), urinalisia, EKG and chest x-ray PA. 8

VI. DIAGNOSIS OF APPEAL

In general, elderly patients with primary hypertension hypertension

or essential hypertension. Secondary hypertension refers to hypertension

the cause can be clearly known (identified) and can be treated. Hypertension

renovascular caused by renal artery stenosis is a common cause

Secondary hypertension can be treated in elderly patients. Other causes such as

apnoe sleep apnea (OSA), primary aldosteronism and thyroid disorders

should be considered in cases where the blood pressure remains above the optimal target

despite therapy with the use of three types of anti-drug regimen

hypertension with a maximum dose, and where history and physical examination

leads to the above mentioned disorders. 2,3,8

Obstructive sleep apnea (OSA) is an independent risk factor and strong

for the progression and the occurrence of hypertension, especially hypertension resistant

and the treatment of renal and cardiovascular complications. Fluid overload and turnover

/ Heat transfer fluids, increasing sympathetic nerve activation, oxidative stress, inflammation, and

release of vaso active substance at the time of intermittent hypoxemia, can

contribute to increased blood pressure in patients with

apne sleep apnea (OSA). 2,3,8

The use of drugs - anti-inflammatory drugs such as NSAIDs can trigger

hypertension. Besides drugs such drugs of cyclooxygenase-2 inhibitor, gluco corticoid,

erythropoietin analog, disease-modifying anti-rheumatic drug (DMARD) (eg:

leflunomide), immunesuppressan (such as: cyclosoprin and tacrolimus), and anti-drug

depressants (such as: venlaxapine higher doses) can increase blood pressure. Drugs

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kind of cocain, ecstasy, nicotine and stimulants (such as methyl phenidate) use and

breaking up the cure reaction may also be associated with hypertension. 2,3,8

Pheochromacytoma is a rare tumor, and responsible

to 0.5% of cases of secondary hypertension are usually found in middle age

between 30-60 years. Intra-cranial tumors in areas close to the nerve

glossopharyngeal could cause kegagaan baroreceptor system, which could

cause labile hypertension (increased blood tekaan suddenly, the

take a few minutes to many hours, tachycardia, and headache) or

orthostatic tachycardia (increased heart rate (heart rate; HR)> 30 times per minute of

the supine position to the position of his feet). 2,3,6, 8

VII. MANAGEMENT

The majority of elderly patients diagnosed with hypertension in the end

use of antihypertensive drug therapy. Treatment of hypertension

pharmacology in the elderly is slightly different from a young age, due to a change

- physiological changes due to the aging process. The physiological changes that occur at the age of

causing further concentration of the drug into larger, drug elimination time becomes

Longer, decreased organ function and response from, the various diseases

Other comorbid (co-morbidities), their drugs for comorbidities

while consumption should be taken into account in the granting of antihypertensive drugs.

Changes in biological systems in the elderly will affect the process of molecular interactions

drugs that ultimately affect the clinical benefit and safety of pharmacotherapy.

The frequency of side effects in the elderly is higher when

compared with the general population. Moreover elderly patients are

one of the patients who are vulnerable to drug interactions. 1

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Figure 3. Algorithms Management of Hypertension in Elderly 16

Targeted treatment of hypertension in the elderly

The general objective of the management of hypertension is to reduce the numbers

morbidity and mortality with treatment with the principle of early diagnosis least-invasive

and the method most cost-effecive. 8

The National Institute for Health and Clinical Excellence (NICE)

recommends a target blood pressure of <140/90 mmHg in the age group

<80 years, and in the age group> 80 years penurunn the target blood pressure <150/90

mmHg. The American College of Cardiology Foundation and the American Heart

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Association (ACCF / AHA) 2011 recommended blood pressure target achievement

Systolic (TDS) 140-145 mmHg. The Seventh Joint National Committee (JNC-7)

recommends a target blood pressure reduction in patients with diabetes and hypertension <

130/80 mmHg regardless of age, but this target is considered to be too aggressive on

mostly elderly patients. 8 According to The Eight Joint National Committee (JNC

8) for Management of High Blood Pressure in Adults 2014, recommends

in the age group ≥60 years of treatment with anti-hypertensive when the pressure

Blood ≥150 / 90 mmHg and a reduction target blood pressure <150/90 mmHg (Level of

Evidence - Grade A). 10

Research ACCORD-BP ( age range: 40-79 years) failed to prove that

decrease the risk of cardio vascular events both fatal and non-fatal decline

systolic blood pressure (TDS) <120 mmHg, compared with a target pressure

Systolic blood (TDS) <140 mmHg in the elderly with diabetes mellitus

who are at high risk for cardiovascular events. This is supported by

INVEST study diabetic sub-group analysis, conducted in the age group

Further with a mean age of 66 years. 8,11,12

Research AASK ( in the age group 18-70 years) showed that

decrease Mean Arterial Pressure (MAP) achieving <92 mmHg do not show

a significant difference (real) against all-cause mortality, mortality due to

cardiovascular attack, when compared with the usual reduction targets MAP

namely between 102-107 mmHg in African populations - Americans who suffer from disease

Chronic kidney (CKD). 8

Research HYVET (Hypertension in the Very Elderly Trial), group

aged over 80 years with a target to reduce blood pressure <150/80 mmHg

showed a decrease in the incidence of stroke, but an increase in numbers

death primarily due to cardio vascular events compared with

a control group taking a placebo. 8.9

Systolic blood pressure (TDS) <120 mmHg may increase the risk of complications

and death from cardiovascular disorders. However, it should be noted that

decrease in blood pressure is achieved gradually and diastolic blood pressure (TDD)

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should not be too low as it can reduce tissue perfusion. pressure control

Blood can prevent dementia in the elderly. 2.3

Management of hypertension in the elderly

Hypertension in the elderly hypertension same as at any other age. Although

the risk of complications is greater. Decreased blood pressure will decrease

risk of morbidity and mortality due to cardiovascular complications. It is appropriate

with results from large studies that have been done on Systolic hypertension and

diastolic produce the same risk reduction. Of many antihypertensive drugs

that is, not all of them have an effect and a good degree of security at the age of

further. Called safe because it does not cause complications or more important is

do not disturb the quality of life of patients. 2,3,13

Management of hypertension stage one without a compelling indication starts

with the change / modification of lifestyle do for three months. When

blood pressure is not controlled with this treatment then continued with therapy

pharmacology. In stage one begins with monotherapy antihypertensive drugs but

on the stage of direct duadianjurkan use two drugs to eliminate the pressure

Blood can be controlled more quickly. By using a combination of drugs then

blood pressure control using two lines so that the pathophysiology of blood pressure

more controllable. Also there is a synergistic effect of the two classes of drugs that benefit

in the control of high blood pressure. 17

The principle of treatment of hypertension in the elderly is always started with the dose

low and gradually increased until mencapa targets, "Start low and go slow". Various

a class of drugs has been shown to lower blood pressure in the elderly, either

single or more often in combination. Diuretics, beta blockers (β-

blockers), calcium channel blocker (CCB), Angiotensin Converting Enzyme -

Inhibitors (ACE-inhibitors), angiotensin receptor blocker (ARB), and the last

is group Direct renin inhibitor (DRI) all have been shown to lower

blood pressure and reduce the morbidity and mortality in hypertensive patients.

In addition to the provision of anti-hypertensive drugs, also made lifestyle modifications,

quitting smoking, managing diabetes, blood lipid levels, administration of anti-aggregation

platelets, exercise physical activity, and obesity lose weight.

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 In the process of aging and cardiovascular complications, generally occurs

declining health, cognitive function, ability of elderly physic activity, and sexual. By

Therefore the selection of drugs and targeted treatment should always observe

Patient quality of life aspects. 2,3,6,8,10

Table 6. Strategic management of hypertension in the elderly 16

reccomendation Class Level

In elderly hypertensives with SBP ≥160 mmHg there is solid evidence to recommend reducing I A
SBP to between 150 and 140 mmHg.
In a fit elderly Patients <80 years old antihypertensive treatment may be onsidered at SBP values IIB C
​≥140 mmHg with a target of SBP <140 mmHg if treatment is well tolerated.

In individuals older than 80 years with an initial SBP ≥160 mmHg it is recommended to reduce I B
SBP to between 150 and 140 mmHg, Provided they are in good physical and mental conditions.

Patients in the frail elderly, it is recommended to leave decisions on I C

antihypertensive therapy to the treating physician, and based on the monitoring of the clinical
effects of treatment.
Continuation of well-tolerated antihypertensive treatment should be Considered when IIA C
octogenarian Becomes a treated individual.
All hypertensive agents are recommended and can be used in the elderly, Although diuretics and I A
calcium antagonists may be preferred in isolated systolic hypertension.

Non-pharmacological treatment

Lifestyle modification is always recommended as the treatment of hypertension in

generally. Even in some patients with mild hypertension in this way can without

drug. The act of smoking cessation, weight control, reduce mental stress,

restriction of salt intake, alcohol, increasing physical activity can all be

reduce blood pressure and also the use of doses of antihypertensive drugs. 2,3,8

The following is a lifestyle modifications that can be done to reduce

blood pressure in elderly patients, among others: 2,3,8,10,13

1. Low-salt diet

Guides of Canada (CHEP 2011) recommends the intake of Na in

food for adults aged <50 years: 1500 mg, ages 51-70 years: 1300 mg and

age> 70 years: 1,200 mg. This recommendation is smaller than the recommended

JNC-7, 2004 that is equal to 2400 mg of sodium (Na) or 6 grams of salt.

According to the USDA recommends consumption of sodium in the age group ≤ 50

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 year is 2300 mg or 6 grams of salt, and in the age group

> 51 years and groups at high risk of cardiovascular disease

The recommended sodium intake is <1,500 grams per day. however

low-salt restricted diet in older age groups are fragile (Frailty) could

cause or even worsen anorexia, malnutrition, sarcopenia and

orthostatic hypotension.

The strongest evidence supporting to make a low-salt diet

(Sodium) in the elderly with hypertension is TONE research,

which states that the common clinical benefit to reduce consumption

berkiasar 2,300 mg of sodium into the age group> 70 years. 8.14

2. Planning a good food menu

Diet according to The Dietary Approaches to Stop Hypertension

(DASH) recommends a diet containing whole grains, fish, poultry,

and beans - beans because it is rich in potassium, magnesium, calcium, protein

and fiber, as well as avoiding the consumption of red meat, sweets and

containing added sugar and sugar-containing beverages. Diet

according to The DASH has been proven to reduce blood pressure in

Short-term studies (for more than 8 weeks of observation) at

mid-adult age groups, but still lack of data on

Long-term monitoring in the older age groups. 8

3. Stop consuming alcohol

Heavy drinkers (> 300 mL / week or 34 g alcohol / day)

independently proven, significant, and strongly correlated with increased

blood pressure, and may also be associated with increased risk of incident

cardiovascular disease, stroke and all causes of death compared

with groups that are not alcoholics (occasional drinking).

4. Regular physical exercise

Doing aerobic physical activity for 30-45 minutes for 4

days or more a week is considered beneficial for the elderly with

hypertension.

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5. Lose weight

The group with the elderly called obesity when body mass index> 30 kg / m 2.

penelian TONE prove that a decline in blood pressure

good weight loss with exercise and with diet restrictions.

However, based on observations during the 12 years of mortality data

of TONE study failed to show benefits in terms of mortality

Among the elderly who undergo weight-loss process when

compared to the elderly who did not undergo intervention

for weight loss. Data in the elderly population

mention that in people suffering from malnutrition (under-weight)

have the same risk for experiencing physical disability compared

by the elderly who are overweight

(Overweight).

6. Quit smoking

The elderly should be encouraged to stop smoking, it can

done with the help of nicotine patches, nicotine gum, as well as with drugs -

medications such as bupropion and varenicline, but strict control

the side effects that may occur such as seizures, schizophrenia, psychosis,

mood disorders, anxiety, skin rash, cardiovascular disorders and disorders

gastrointestinal such as nausea and vomiting.

7. avoiding polypharmacy

Avoid the use of drugs - other drugs simultaneously potentially

to raise blood pressure such as class NSAIDs, should be stopped

or considered its use and by comparing the benefits

obtained by the loss realized on the patient.

8. Consuming "dark chocolate"

Dark Chocolate rich in "polyphenols" has proven to

lowering blood pressure in various studies. But has not provided the data

showed clinical benefit on stroke risk reduction and attacks

heart.

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Table 7. Lifestyle Modification on Penatalaksaan Hypertension in the Elderly 15

Initial treatment in uncomplicated hypertension

Consensus management of hypertension in the elderly divided medicine

initials into hypertension without complications and hypertension with complications.

Based on the latest results of a meta-analysis, recommendations initiation of therapy in elderly

Uncomplicated is class thiazide diuretics, Calcium channel blocker (CCB),

Angiotensin converting enzyme - inhibitors (ACE-inhibitors), angiotensin receptor

Blockers (ARBs), beta blockers (β-blockers). 2,3,8

Recommendations of Canada (Canadian Hypertension Education Program; CHEP)

does not recommend using inhibitors of receptor beta (β-blockers) remember

number of cases of chronic obstructive pulmonary disease (PPOM) in the elderly.

Most elderly require two or more antihypertensive medications to achieve

the desired blood pressure targets. Recommendations JNC-7, the European Society of

Hypertension and others, treatment is initiated using two anti

hypertension when blood pressure of 20/10 mm Hg already exceeded the target pressure

blood. 2,3,8 Before adding a new antihypertensive drug, possible reasons

inadequate previous antihypertensive treatment should be evaluated, including

therein compliance, fluid overload, drug interactions (use of NSAIDs, caffeine, anti

depressants, nasal decongestants containing sympathomimetic) and situations

related conditions such as obesity, smoking, excessive alcohol consumption,

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insulin resistance, and pseudoresistensi. Pseudoresistensi is a response

Inadequate against antihypertensive therapy caused by blood pressure measurement

The clinic is a false positive or a higher blood pressure when compared to

Blood pressure measurements outside the clinic as well as ABPM HBPM. 15,16,17

In the initial treatment of Hypertension with complications

Last consensus recommends the selection of drugs in elderly patients

with complications, according to the results of clinical trials of drugs on indications or complications

particular, gained from long-term studies or meta-analyzes. on guide

JNC -7, this indication is referred to as " Compelling indication ".

Table 8. Compelling indications for the treatment of hypertension in the elderly.

COMPLICATIONS DISEASES ANTI-HYPERTENSION DRUG CHOICE

Heart failure Thiazides, BB, ACE-I, ARB, CCB, Aldosterone Antagonist

Post-Infarction Heart BB, ACE-I, Aldosterone Antagonist, ARB

Ischemic heart disease, or high risk of

Thiazides, BB, ACE-I, CCB
cardiovascular disease
angina pectoris BB, CCB

Aorta aneurysm BB, ARBs, ACE-I, CCB, thiazides, BB

DM ACE-I, ARB, CCB, thiazides, BB

Chronic Kidney Disease ACE-I, ARB, CCB, thiazides, BB

Recurrent Stroke Prevention Thiazide, ACE-I, ARB, CCB

Quoted from Science Textbook In the disease, Issue VI 2014 2

• The combination is
recommended
• The combination of
useful (with few restrictions)

• It's still possible but a

little research on its use

• The combination is not

recommended

Figure 4. Combination use of antihypertensive drugs

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Table 9. Side Effects of Antihypertensive Treatment in Elderly 16

Here is a class of anti-hypertensive drugs that can be used in older patients

further: 2,3,6,8,10,13,15,16

a. diuretics

Diuretics are often used in the elderly, especially thiazide class of antagonists

aldosterone. Loop diuretics are very strong diuretic is given if there is

heart failure or chronic kidney disease (CKD). Non-thiazide diuretics

as indapamid is a derivative of sulfonamide, can reduce morbidity

cardiovascular or stroke in those aged> 80 years. Side effects that need to be

note is the increase in blood sugar levels.

b. Calcium channel blocker (CCB)

Drugs known as calcium antagonists or calcium channel blocker (CCB) has

proven safety and efficacy in the treatment of hypertension in the elderly.

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 CCB is recommended especially when there are comorbid cardiovascular disease.

Drugs given is that have a long working time. Research

Accomplish shows that the use of amlodipine (CCB group

dyhidropiridine) is more effective than thiazide in reducing

cardiovascular events in patients at high risk, including diabetes and

is a good alternative choice for the treatment of hypertension with

diabetes. Non-dihydropyridine CCB groups such as diltiazem and verapamil

do not have the inotropic and chronotropic effects on systolic function

left ventricular heart when compared with the class of dihydropyridine CCB

such as amlodipine or felodipine. Verapamil and diltiazem can be used

as adjunctive therapy in hypertensive patients with renal parenchymal disease

(Pharenchymal renal disease) and hypertension resistant, but should

avoid use in patients with left ventricular dysfunction.

c. Angiotensin Converting Enzyme - Inhibitors and Receptor Blocker

Angiotensin converting enzyme - inhibitors (ACE-inhibitors) and angiotensin

Receptor Blocker (ARB) is a drug that works by inhibiting system

renin - angiotensin. These drugs have been shown to have an effect beyond the effect of decreasing

blood pressure. In hypertensive cardiovascular risk, drug

- This class of drugs capable of repairing or inhibit organ abnormalities

target occurs. LIFE study showed a decrease in mortality

incidence of cardiovascular and stroke in patients with isolated systolic hypertension

(HST) with the administration of losartan (ARB) compared with atenolol (Beta

blockers). Due to have renoprotective effects of drugs known as Ace-

Inhibitors and ARBs in patients with type 2 diabetes mellitus, the management guidelines /

The latest anti-hypertension guidelines recommend the use of one of these drugs

as initial therapy in hypertensive elderly with diabetes mellitus. Effect

ACE-inhibitor side groups that often occurs is a dry cough

caused by bradykinin, when this happens ACE-inhibitors should be discontinued

and replaced with group Angiotensin Receptor Blocker (ARB) as

valsartan or losartan. JNC -8 through recommendation 9 does not allow

the use of ACE-inhibitors and ARBs simultaneously on one paien.

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d. Direct renin inhibitor (DRI)

Direct renin inhibitor (DRI) is an anti-hypertensive drug classes new

with similar effectiveness to ACE-inhibitor or ARB. aliskiren is

the only drug of this class available DRI can be combined

with other drugs such as HCT, ramipril and amlodipine. No data

sufficient in patients with eGFR less than 30 ml / min.

e. beta Blocker

Class of beta blockers (beta blockers) such as propranolol, bisoprolol, atenolol,

and others are no longer recommended as initial therapy in the treatment of

elderly hypertension due to side effects were great, especially on

respiratory tract, except in heart failure, coronary heart disease, migraine

and senile tremor. In hypertensive drugs of this class are usually given as

combination with a diuretic.

f. alpha Blocker

Group seletif alpha 1 adrenergic antagonist such as terazosin and doxazosin

useful for the treatment of hypertension accompanied with benign prostatic

hypertrophy (BPH). The main side effects of drugs known as alpha blockers are

orthostatic hypotension, reflex tachycardia, and headache. penilitian ALLHAT

showed side effects such as increased risk of stroke, the incidence

cardio vascular disease and an increased risk of congestive heart

doxazozin use when compared with chlortalidone, p this

showed that the use of class alpha antagonists should be avoided

as a first-line use of antihypertensive drugs.

g. aldosterone Antagonist

Class of aldosterone antagonist such as spironolactone is usually used in

resistant hypertension caused by primary hyperaldosteronism and

apnoe sleep apnea (OSA).

h. Anti-hypertension group lainnnya

Class of drugs that work on the central as clonidine, not recommended use

at the start of therapy given sedation, drowsiness, bradycardia, and dry mouth.

In addition the use of these drugs in the elderly is feared could lead to

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 the occurrence of hypertensive crisis due to sudden withdrawal of the drug (withdrawal

effect). Clonidine can be administered in combination with drugs - drugs

another to achieve optimal blood pressure target.

Elderly Hypertension Management in Special Circumstances

Hypertension with diabetes

Based on the guidelines JNC-8 in the age group ≥ 18 years with diabetes

mellitus, treatment with anti-hypertensive blood pressure ≥ 140/90 mmHg,

and the optimal target blood pressure reduction at is <140/90 mmHg (Level of

Evidence E; expert opinion). In the general population who were not black, choice

initial treatment of antihypertensive drugs are a class of diuretic thiazides, calcium antagonists

(CCB), ACE-inhibitors and Angiotensin Receptor Blocker (ARB) (Level of Evidence B).

On the black population with diabetes mellitus main choice of antihypertensive drugs

is the class of thiazide diuretics or calcium antagonist class of anti-hypertension

(Calcium Channel Blockers) (Level of Evidence C). This is consistent with research

ALLHAT which showed that thiazide diuretics penggunana proven to be more effective

in reducing the risk of cerebrovascular, cardiovascular events, and failed

heart compared with the ACE-inhibitor group in the population is black.

Likewise with the calcium antagonist class of anti-hypertension is superior when

compared with the ACE-inhibitor group, but the differences were not found

significantly between thiazides with CCB in terms of cardiovascular benefits as well as

other clinical complications. Another option is the use of one of the group Ace-

Inhibitor or ARB. 8.10

Hypertension with Chronic Kidney Disease (CKD)

Based on the guidelines JNC-8 in the age group ≥ 18 years of age with kidney disease

Chronic (PGK), start treatment with anti-hypertensive blood pressure ≥ 140/90

mmHg, and the optimal target blood pressure reduction at is <140/90 mmHg (Level

Of Evidence E; expert opinion). Antihypertensive drug selection initials to improve

renal function is the class of ACE-inhibitors and Angiotensin Receptor Blocker (ARB).

This applies to all patients with chronic kidney disease (CKD) with hypertension

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regardless of race or diabetes. (Level of Evidence B). ACE-Inhibitor

or Angiotensin Receptor Blocker (ARB) is recommended when found their

proteinuria> 300 mg / day, or in conjunction with heart failure. However, research

AASK failed to prove the existence of a decrease in cardiovascular events with

the use of beta blockers compared with ACE-inhibitors compared to

Calcium antagonists (CCB) amlodipine group type of Afro-Americans who suffer

hypertension with chronic kidney disease (CKD). 8.10

Hypertension with Heart Failure

The elderly with systolic hypertension and heart failure (Systolic Heart

Failure; SHF) should be treated with antihypertensive diuretics, beta blockers,

ACE-inhibitors and aldosterone antagonists if not found the existence of hyperkalemia and

Significant impairment of renal function. Hypertensive patients with ventricular dysfunction

Left asymptomatic (asymptomatic left ventricular dysfunction) should

using class beta blockers and ACE-inhibitors. Diastolic heart failure is often

common in elderly patients. Fluid retention should be treated adequately

by administration diretik loop, hypertension should be controlled, and comorbid illnesses

others must be addressed immediately. 8.10

resistant hypertension

Known as resistant hypertension when blood pressure can not be lowered

hit the target with the use of three antihypertensive drug regimen once, including

diuretics (coupled with ACE-inhibitors, calcium antagonists, beta blockers

or Angiotensin Receptor Blocker) and each - each of the three drugs

has reached or approached the maximum recommended dose. On

sitolik isolated hypertensive patients (HST) in the elderly, is said to be resistant hypertension

when encountered inability to lower systolic blood pressure be

below 160 mmHg using three anti-hypertension drug regimen once. 8.10

The main causes of resistant hypertension were: noncompliance in

taking prescription drugs and low-salt diet, medication dosing is too

low, drug interactions, pseudotolerance (salt, water retention), secondary hypertension, pseudo

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hipertension and white coat / office hypertension. Selection of antihypertensive drugs that can

is used as a supplemental regimen in resistant hypertension is the clonidine group.

The use of clonidine orally or transdermal patch or anti

hypertension who works as a central simpatolitik others may be used at a dose

low to reduce the effects of sedation and orthostatic hypotension. The use of minoxidil,

reserpine and hydralazine should be used with caution due to high

side effects caused, especially in elderly patients. 8

Table 10. The dose of antihypertensive drugs (JNC 8) 10

Abbreviations: ACE, angiotensin-converting enzyme; RCT, randomized controlled trial. aCurrent recommended
evidence-based dose that balances efficacy and safety is 25-50 mg daily.

Table 11. Recommended treatment of hypertension according to JNC 8 10

Recommendation 1
In the general population aged _60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood
pressure (SBP) _150 mm Hg or diastolic blood pressure (DBP) _90mmHg and treat to a goal of SBP <150 mm Hg and the
goal DBP <90 mm Hg. (Strong Recommendation - Grade A)

Corollary Recommendation
In the general population aged ≥ 60years, if pharmacologic treatment for high BP Achieved results in lower SBP (eg,
<140mmHg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need
to be adjusted. (Expert Opinion - Grade E)

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Recommendation 2
In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥ 90 mmHg and treat to a goal
DBP ≥ 90mmHg. (For ages 30-59 years, Strong Recommendation - Grade A; For ages 18-29 years, Expert Opinion -
Grade E)

Recommendation 3
In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥ 140mmHg and treat to a goal
SBP <140mmHg. (Expert Opinion - Grade E)

Recommendation 4
In the population aged ≥ 18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP
≥ 140 mmHg or DBP ≥ 90 mmHg and treat to goal SBP <140 mmHg and DBP goal <90mmHg. (Expert Opinion - Grade E)

Recommendation 5
In the population aged ≥ 18years with diabetes, initiate pharmacologic treatment to lower BP at SBP ≥ 140mmHgorDBP ≥
90 mmHg and treat to a goal SBP <140 mmHg and goal DBP <90 mmHg. (Expert Opinion - Grade E)

Recommendation 6
In the general non-black population, Including Reviews those with diabetes, initial antihypertensive treatment should include
a thiazide-type diuretics, calcium channel blockers (CCB), angiotensinconverting enzyme inhibitors (ACEI) or angiotensin
receptor blocker (ARB). (Moderate Recommendation - Grade B)

Recommendation 7
In the general black population, Including thosewith diabetes, initial antihypertensive treatment should include a
thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation - Grade B; for Black Patients with
diabetes: Weak Recommendation - Grade C)

Recommendation 8
In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to
improve kidney outcomes. This Applies to all CKD Regardless of race patientswith hypertension nor diabetes status.
(Moderate Recommendation - Grade B)

The main objective of hypertension treatment is to ATTAIN and maintain goal BP. If goal BP is not Reached within
amonth of treatment, increase of the dose of the initial drug or add a second drug from one of
the classes in recommendation 6 (a thiazide-type diuretic, CCB,
ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is Reached. If
goal BP can not be Reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ARB and an
ACE Ihibitor together in the same patient. If Goal Reached BP can not only using the drugs in recommendation 6 because
of contraindication or the need to use more than 3 drugs to reach goal BP, anti-hypertensive drugs from other classes can
be used. Referral to a hypertension specialist may be indicated resources for Patients in Whom BP goal can not be attained
using the above strategy or for the management of compicated Patients For Whom additional clinical consultation is
needed. (Expert Opinion - Grade E)

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Figure 5. Algorithm Free Treatment of Hypertension in 2014 according to JNC-8 10

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Table 12. Strategy and doses of antihypertensive drug use (Adapted from JNC 8) 10

Table 13. Comparison of blood pressure targets and When starting antihypertensive treatment in adults (Adapted
from JNC 8) 10

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VIII. CONCLUSION

The prevalence of hypertension in the elderly is higher compared to patients

a younger age. Most of hypertension in the elderly is

primary hypertension and isolated systolic hypertension (HST). Diagnosis of hypertension same

with other hypertension diagnosis is based on the measurement of blood pressure

correct and appropriate guideline / guidelines of the WHO and JNC VII. The mechanism of hypertension

in old age is not fully known, increased arterial stiffness, dysfunction

endothelial, dysregulation of the autonomic nervous system, microvascular damage to the kidneys,

baro receptors and decreased sensitivity to sodium retention is believed to be

the mechanism of hypertension in the elderly. Management of hypertension at age

Further in principle no different with hypertension in general, which is composed of

lifestyle modification and when needed can be continued with the drug-

antihypertensive drugs. Drugs commonly used are diuretics and

calcium antagonists with the principle of start low and go slow. Treatment of hypertension

the elderly began when TDS ≥ 150 mmHg and TDD ≥ 90 mmHg, and the target

diingin blood pressure was achieved in the management of hypertension in the elderly

according to the JNC 8 is <150/90 mmHg, and when accompanied by comorbid diseases such as

diabetes mellitus and hypertension becomes lower, <140/90 mmHg.

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